U.S. Military use of tourniquets from 2001 to 2010

Next-generation tourniquet: Recommendations for future capabilities and design requirements

BACKGROUND

Advances in tourniquet development must meet new military needs for future large-scale combat operations or civilian mass casualty scenarios. This includes the potential use of engineering and automation technologies to provide advanced tourniquet features. A comprehensive set of design capabilities and requirements for an intelligent or smart tourniquet needed to meet the challenges currently does not exist. The goal of this project was to identify key features and capabilities that should be considered for the development of next-generation tourniquets.

METHODS

We used a modified Delphi consensus technique to survey a panel of 34 tourniquet subject matter experts to rate various statements and potential design characteristics relevant to tourniquets systems and their use scenarios. Three iterative rounds of surveys were held, followed by virtual working group meetings, to determine importance or agreement with any given statement. We used a tiered consensus system to determine final agreement over key features that were viewed as important or unimportant features or capabilities. This information was used to refine and clarify the necessary tourniquet design features and adjust questions for the following surveys.

RESULTS

Key features and capabilities of various were agreed upon by the panelists when consensus was reached. Some tourniquet features that were agreed upon included but are not limited to: Capable of being used longer than 2 hours, applied and monitored by anyone, data displays, semiautomated capabilities with inherent overrides, automated monitoring with notifications and alerts, and provide recommended actions.

CONCLUSION

We were able to identify key tourniquet features that will be important for future device development. These consensus results can guide future inventors, researchers, and manufacturers to develop a portfolio of next-generation tourniquets for enhancing the capabilities of a prehospital medical provider.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level V.

Implementing Tourniquet Conversion Guidelines for Civilian EMS and Prehospital Organizations : A Case Report and Review

Since the first documented use of a tourniquet in 1674, the popularity of tourniquets has waxed and waned. During recent wars and more recently in Emergency Medical Services systems, the tourniquet has been proven to be a valuable tool in the treatment of life-threatening hemorrhage. However, tourniquet use is not without risk, and several studies have demonstrated adverse events and morbidity associated with tourniquet use in the prehospital setting, particularly when left in place for more than 2 h. Consequently, the US military's Committee on Tactical Combat Casualty Care has recommended guidelines for prehospital tourniquet conversion to reduce the risk of adverse events associated with tourniquets once the initial hemorrhage has been controlled. Emergency Medical Services systems that operate in rural, frontier, and austere environments, especially those with transport times to definitive care that routinely exceed 2 h, may consider implementing similar tourniquet conversion guidelines.

Observations from the Korean War for Modern Military Medicine

This paper reviews developments in military medicine during the Korean War and places them in the evolution of military medical lessons from the Second World War and the subsequent development of military medicine through the Vietnam War to the present day. The analysis is structured according to the '10 Instruments of Military Healthcare.' Whilst there were incremental developments in military medicine in all these areas, several innovations are specifically attributed to the Korean War. The introduction of helicopters to the battlefield led to the establishment of dedicated medical evacuation helicopters crewed with medical personnel and the evolution into the DUSTOFF system during the Vietnam War. Helicopter evacuation was the primary medical evacuation system in the wars in Iraq and Afghanistan. The establishment of the Mobile Army Surgical Hospital during the Korean War were founded upon the US Auxiliary Surgical Groups or the UK Casualty Clearing Stations of World War II. The requirement for resuscitation and surgical teams close to the battlefield has endured through the development of mobile hospitals of varying sizes from Field Surgical Teams to the current 'modular' Hospital Centre and other international equivalents. There were many innovations in the clinical care of battle casualties covering wound shock, surgical techniques, preventive medicine, and acute psychiatric care that refreshed or advanced knowledge from the Second World War. These were enabled through the establishment of medical research programs that were managed within the theatre of operations. Further advances in all these clinical topics can be observed through the Vietnam War to the wars in Iraq and Afghanistan - all of which were underpinned by institutional directed research programs. Finally, collaboration between international military medical services and the development of Korean military medical services is a major theme of this review. This 'military-tomilitary' and 'civil-military' medical engagement was also a major activity during the Vietnam War and more recently in Iraq and Afghanistan. Overall, the topics and themes in military medicine that were important during the Korean War can be considered to be part of trajectory of innovation in military medicine have been replicated in many subsequent wars. The paper also highlights some 'lessons' from World War II that had to be relearned in the Korean War, and some observations from the Korean War that had to be relearned in subsequent wars.

[The chapters "Stop the bleed-prehospital" and "Coagulation management and volume therapy (emergency departement)" in the new S3 guideline "Polytrauma/severe injury treatment"]

The S3 guideline on the treatment of patients with severe/multiple injuries by the German Association of the Scientific Medical Societies was updated between 2020 and 2022. This article describes the essence of the new chapter "Stop the bleed-prehospital" and the revised chapter "Coagulation management and volume therapy".

Adherence to a Balanced Approach to Massive Transfusion in Combat Casualties

BACKGROUND

Hemorrhage is the most common cause of potentially preventable death on the battlefield. Balanced resuscitation with plasma, platelets, and packed red blood cells (PRBCs) in a 1:1:1 ratio, if whole blood (WB) is not available, is associated with optimal outcomes among patients with hemorrhage. We describe the use of balanced resuscitation among combat casualties undergoing massive transfusion.

MATERIALS AND METHODS

We conducted a secondary analysis of data from the Department of Defense Trauma Registry (DODTR) spanning encounters from January 1, 2007, to March 17, 2020. We included all casualties who received at least 10 units of either PRBCs or WB. We categorized casualties as recipients of plasma-balanced resuscitation if the ratio of plasma to PRBC units was 0.8 or greater; similarly, we defined platelet-balanced resuscitation as a ratio of platelets to PRBC units of 0.8 or greater. We portrayed these populations using descriptive statistics and compared characteristics between non-balanced and balanced resuscitation recipients for both plasma and platelets.

RESULTS

We identified 28,950 encounters in the DODTR with documentation of prehospital activity. Massive transfusions occurred for 2,414 (8.3%) casualties, among whom 1,593 (66.0%) received a plasma-balanced resuscitation and 1,248 (51.7%) received a platelet-balanced resuscitation. During the study period, 962 (39.8%) of these patients received a fully balanced resuscitation with regard to both the plasma:PRBC and platelet:PRBC ratios. The remaining casualties did not undergo a balanced resuscitation.

CONCLUSIONS

While a majority of massive transfusion recipients received a plasma-balanced and/or platelet-balanced resuscitation, fewer patients received a platelet-balanced resuscitation. These findings suggest that more emphasis in training and supply may be necessary to optimize blood product resuscitation ratios.

The tight rope act: A multicenter regional experience of tourniquets in acute trauma resuscitation

BACKGROUND

As tourniquets have become more prevalent, device use has been questioned. This study sought to characterize the incidence, indication, and efficacy of tourniquet placement in acute trauma resuscitation.

METHODS

Nine regional level 1 trauma centers prospectively enrolled for 12 months adult patients (18 years or older) who had a tourniquet placed. Age, sex, mechanism, tourniquet type, indication, applying personnel, location placed, level of occlusion, and degree of hemostasis were collected. Major vascular injury, imaging and operations performed, and outcomes were assessed. Analyses were performed with significance at p < 0.05.

RESULTS

A total of 216 tourniquet applications were reported on 209 patients. There were significantly more male patients (183 [88%]) and penetrating injuries (186 [89%]) with gunshots being most common (127 [61%]). Commercial tourniquets were most often used (205 [95%]). Ninety-two percent were placed in the prehospital setting (by fire/paramedics, 56%; police, 33%; bystanders, 2%). The most common indications were pooling (47%) and pulsatile (32%) hemorrhage. Only 2% were for amputation. The most frequent location was high proximal extremity (70%). Four percent were placed over the wound, and 0.5% were distal to the wound. Only 61% of applications were arterial occlusive. Median application time was 30 minutes (interquartile range, 20-40 minutes). Imaging was performed in 54% of patients. Overall, 36% had a named arterial injury. Tourniquet application failed to achieve hemostasis in 22% of patients with a named vascular injury. There was no difference in hemostasis between those with and without vascular injury (p = 0.12) or between who placed the tourniquet (p = 0.07). Seventy patients (34%) required vascular operations. Thirty-four percent of patients were discharged home without admission.

CONCLUSION

Discerning which injuries require tourniquets over pressure dressings remains elusive. Trained responders had high rates of superfluous and inadequate deployments. As tourniquets continue to be disseminated, emphasis should be placed on improving education, device development, and quality control.

LEVEL OF EVIDENCE

Prognostic/Epidemiologic, Level III.

Prehospital Tourniquet Usage and Diabetes Mellitus Associated with Increased Incidence, Odds, and Risk of Acute Kidney Injury: A Pilot Study

INTRODUCTION

Tourniquets are the standard of care for civilian and military prehospital treatment of massive extremity hemorrhages. Over the past 17 years, multiple military studies have demonstrated rare complications related to tourniquet usage. These studies may not translate well to civilian populations due to differences in baseline health. Experimental studies have demonstrated increased rates of post-traumatic acute kidney injuries (AKIs) in rats with obesity and increased oxidative stress, suggesting that comorbidities may affect AKI incidence with tourniquet usage. Two recently published retrospective studies, focused on the safety of tourniquets deployed within civilian sectors, documented increased incidence of AKI in patients with a prehospital tourniquet as compared to previously published military results. This study aimed to provide descriptive data concerning the association between the use of prehospital tourniquets and AKIs amongst civilian patient populations as AKIs increase mortality in hospitalized patients.

METHODS

This was a single-center, observational, cross-sectional, pilot study involving chart review of participants presenting to a tertiary Level 1 trauma center. Patient data were extracted from prehospital and hospital electronic medical records. For this study, AKI was defined using the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines.

RESULTS

A total of 255 participants were included. Participants with a history of diabetes mellitus had a significantly higher incidence of AKI as compared to those without. Analysis revealed an increased odds of AKI with diabetes in association to the use of a prehospital tourniquet. Participants with diabetes had an increased relative risk of AKI in association to the use of a prehospital tourniquet. The incidence of AKI was statistically higher than what was previous reported in the military population in association with the use of a prehospital tourniquet.

CONCLUSION

The incidence of AKIs was higher than previously reported. Patients with diabetes had an associated higher risk and incidence of sustaining an AKI after the use of a prehospital tourniquet in association with the use of a prehospital tourniquet. This may be due to the known deleterious effects of diabetes mellitus on renal function. This study provides clinically relevant data that warrant further multi-site investigations to further investigate this study's associated findings and potential causation. It also stresses the need to assess whether renally-impacting environmental and nutritional stressors affect AKI rates amongst military personnel and others in which prehospital tourniquets are used.

Prehospital Tourniquets Placed on Limbs Without Major Vascular Injuries, has the Pendulum Swung Too far?

BACKGROUND

Combat applications of tourniquets for extremity trauma have led to increased civilian prehospital tourniquet use. Studies have demonstrated that appropriate prehospital tourniquet application can decrease the incidence of arrival in shock without increasing limb complications. The aim of this study was to examine outcomes of prehospital tourniquet placement without definitive vascular injury.

METHODS

Retrospective review was performed of a prospectively maintained database by the American Association for the Surgery of Trauma from 29 trauma centers. Patients in this subset analysis did not have a significant vascular injury as determined by imaging or intra-operatively. Patients who received prehospital tourniquets (PHTQ) were compared to patients without prehospital tourniquets (No-PHTQ). Outcomes were amputation rates, nerve palsy, compartment syndrome, and in-hospital mortality.

RESULTS

A total of 622 patients had no major vascular injury. The incidence of patients without major vascular injury was higher in the PHTQ group (n = 585/962, 60.8 vs n = 37/88, 42.0%, P < .001). Cohorts were similar in age, gender, penetrating mechanism, injury severity scores (ISS), abbreviated injury score (AIS), and mortality (P > .05). Amputation rates were 8.3% (n = 49/585) in the PHTQ group compared to 0% (n = 0/37) in the No-PHTQ group. Amputation rates were higher in PHTQ than No-PHTQ with similar ISS and AIS (P = .96, P = .59). The incidence of nerve palsy and compartment syndrome was not different (P > .05).

CONCLUSIONS

This study showed a significant amount of prehospital tourniquets are being placed on patients without vascular injuries. Further studies are needed to elucidate the appropriateness of prehospital tourniquets, including targeted education of tourniquet placement.

Reciprocal Learning Between Military and Civilian Surgeons: Past and Future Paths for Medical Innovation

Numerous surgical advances have resulted from exchanges between military and civilian surgeons. As part of the U.S. National Library of Medicine Michael E. DeBakey Fellowship in the History of Medicine, we conducted archival research to shed light on the lessons that civilian surgery has learned from the military system and vice-versa. Several historical case studies highlight the need for immersive programs where surgeons from the military and civilian sectors can gain exposure to the techniques, expertise, and institutional knowledge the other domain provides. Our findings demonstrate the benefits and promise of structured programs to promote reciprocal learning between military and civilian surgery.

The Impact of a Mobile Phone Application for Retention of Bleeding Control Skills

BACKGROUND

The American College of Surgeons Bleeding Control Course (B-Con) empowers bystanders with hemorrhage control skills to manage prehospital emergencies, but demonstrates poor skill retention. The point of care use of a free Stop the Bleed mobile phone application on the retention of hemorrhage control skills from the B-Con Course was explored.

METHODS

Convenience sample of college students previously trained in B-Con were randomized into mobile application (MA) or control groups. The use of a mobile application during a simulated emergency scenario with tourniquet and situational awareness skills was assessed. Wound packing skill retention without intervention was also assessed. Survey data allowed for comparison of participant perceptions of skills with actual performances.

RESULTS

MA (n = 30) was superior to control (n = 32) in correct tourniquet application (62.5% versus 30.0%; P = 0.01) with longer placement times (163 sec versus 95 sec; P < 0.001) and in calling 911 (31.3% versus 3.3%, P = 0.004). Participants maintain inflated perceptions of their skills, but generally feel underprepared for a future bleeding emergency.

CONCLUSIONS

Mobile apps improve tourniquet and situational awareness skills and may serve as potential aids to improve bystander hemorrhage control skills in real-time, but require further prospective investigation into its use.

Lower extremity reconstruction for limb salvage and functional restoration - The Combat experience

Evolution in extremity injury treatment often occurs during major conflicts, with lessons learned applied and translated among military and civilian settings. In recent periods of war, improvements in protective equipment, in-theater damage control resuscitation/surgery, delivery of antibiotics locally/systemically, and rapid evacuation to higher levels of medical care capabilities have greatly improved combat casualty survivability rates. Additionally, widespread application of lower extremity tourniquets also has prevented casualties from exsanguination, thus reducing hemorrhagic-related deaths. Secondary to these, a high number of combat casualties suffering lower extremity traumatic injuries have presented for functional limb reconstruction and restoration as well as residual limb care.

Lessons Learned From the Battlefield and Applicability to Veterinary Medicine-Part 1: Hemorrhage Control

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.

Tactical Combat Casualty Care Training, Knowledge, and Utilization in the US Army

INTRODUCTION

Tactical Combat Casualty Care (TCCC) is the execution of prehospital trauma skills in the combat environment. TCCC was recognized by the 2018 Department of Defense Instruction on Medical Readiness Training as a critical wartime task. This study examines the training, understanding, and utilization of TCCC principles and guidelines among US Army medical providers and examines provider confidence of medics in performing TCCC skills.

MATERIALS AND METHODS

A cross-sectional survey, developed by members of the Committee on TCCC, was distributed to all US Army Physicians and Physician Assistants via anonymous electronic communication.

RESULTS

A total of 613 completed surveys were included in the analyses. Logistic regression analyses were conducted on: TCCC test score of 80% or higher, confidence with medic utilization of TCCC, and medic utilization of ketamine in accordance with TCCC.

CONCLUSIONS

<60% of respondents expressed confidence in the ability of the medics to perform all TCCC skills. Supervising providers who that believed 80 to 100% of their medics had completed TCCC training had more confidence in their medic's TCCC abilities. With TCCC, a recognized lifesaver on the battlefield, continued training and utilization of TCCC concepts are paramount for deploying personnel.

Prehospital Tourniquets in Civilians: A Systematic Review

OBJECTIVES

Terrorist attacks and civilian mass-casualty events are frequent, and some countries have implemented tourniquet use for uncontrollable extremity bleeding in civilian settings. The aim of this study was to summarize current knowledge on the use of prehospital tourniquets to assess whether their use increases the survival rate in civilian patients with life-threatening hemorrhages from the extremities.

DESIGN

Systematic literature review in Medline (Ovid), Embase (Ovid), Cochrane Library, and Epistemonikos was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines. The search was performed in January 2019.

SETTING

All types of studies that examined use of tourniquets in a prehospital setting published after January 1, 2000 were included.

PRIMARY/SECONDARY OUTCOMES

The primary outcome was mortality with and without tourniquet, while adverse effects of tourniquet use were secondary outcomes.

RESULTS

Among 3,460 screened records, 55 studies were identified as relevant. The studies were highly heterogeneous with low quality of evidence. Most studies reported increased survival in the tourniquet group, but few had relevant comparators, and the survival benefit was difficult to estimate. Most studies reported a reduced need for blood transfusion, with few and mainly transient adverse effects from tourniquet use.

CONCLUSION

Despite relatively low evidence, the studies consistently suggested that the use of commercial tourniquets in a civilian setting to control life-threatening extremity hemorrhage seemed to be associated with improved survival, reduced need for blood transfusion, and few and transient adverse effects.

2020 International Consensus on First Aid Science With Treatment Recommendations

This is the summary publication of the International Liaison Committee on Resuscitation's 2020 International Consensus on First Aid Science With Treatment Recommendations. It addresses the most recent published evidence reviewed by the First Aid Task Force science experts. This summary addresses the topics of first aid methods of glucose administration for hypoglycemia; techniques for cooling of exertional hyperthermia and heatstroke; recognition of acute stroke; the use of supplementary oxygen in acute stroke; early or first aid use of aspirin for chest pain; control of life- threatening bleeding through the use of tourniquets, haemostatic dressings, direct pressure, or pressure devices; the use of a compression wrap for closed extremity joint injuries; and temporary storage of an avulsed tooth. Additional summaries of scoping reviews are presented for the use of a recovery position, recognition of a concussion, and 6 other first aid topics. The First Aid Task Force has assessed, discussed, and debated the certainty of evidence on the basis of Grading of Recommendations, Assessment, Development, and Evaluation criteria and present their consensus treatment recommendations with evidence-to-decision highlights and identified priority knowledge gaps for future research. The 2020 International Consensus on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) Science With Treatment Recommendations (CoSTR) is the fourth in a series of annual summary publications from the International Liaison Committee on Resuscitation (ILCOR). This 2020 CoSTR for first aid includes new topics addressed by systematic reviews performed within the past 12 months. It also includes updates of the first aid treatment recommendations published from 2010 through 2019 that are based on additional evidence evaluations and updates. As a result, this 2020 CoSTR for first aid represents the most comprehensive update since 2010.

2020 International Consensus on First Aid Science With Treatment Recommendations

This is the summary publication of the International Liaison Committee on Resuscitation's 2020 International Consensus on First Aid Science With Treatment Recommendations. It addresses the most recent published evidence reviewed by the First Aid Task Force science experts. This summary addresses the topics of first aid methods of glucose administration for hypoglycemia; techniques for cooling of exertional hyperthermia and heatstroke; recognition of acute stroke; the use of supplementary oxygen in acute stroke; early or first aid use of aspirin for chest pain; control of life-threatening bleeding through the use of tourniquets, hemostatic dressings, direct pressure, or pressure devices; the use of a compression wrap for closed extremity joint injuries; and temporary storage of an avulsed tooth. Additional summaries of scoping reviews are presented for the use of a recovery position, recognition of a concussion, and 6 other first aid topics. The First Aid Task Force has assessed, discussed, and debated the certainty of evidence on the basis of Grading of Recommendations, Assessment, Development, and Evaluation criteria and present their consensus treatment recommendations with evidence-to-decision highlights and identified priority knowledge gaps for future research.

The effects of military-wide introduction of advanced tourniquets in the Israel Defense Forces

BACKGROUND

Early application of tourniquets has reduced injury death rates. At the end of 2013, the Israel Defense Forces Medical Corps completed a military-wide introduction of the Combat Application Tourniquet as the standard-issued tourniquet. The accompanying clinical practice guideline encouraged combat soldiers and medical teams towards a liberal use of tourniquets for extremity injuries, even when in doubt.

OBJECTIVES

This study aimed to assess the effects of the wide introduction of advanced tourniquets on the rate of tourniquet applications, the type of tourniquet applied, and the differences in hospitalisation outcomes following the introduction.

METHODS

The study population was composed of hospitalised military casualties with an extremity injury treated by military medical teams between 2006 and 2015. Prehospital data were extracted from the Israel Defense Forces Trauma Registry and matched to corresponding hospital data from the Israeli National Trauma Registry. Two periods were compared: 2006-2013 "pre-intervention period" and 2014-2015 "post-intervention period".

RESULTS

A total of 1,578 casualties were recorded during the study period. Of these, 320 (20.3%) occurred between 2014-2015. Characteristics of casualties in the post-intervention period were similar to those in the pre-intervention period including the rate of traumatic amputations (2.5% vs 2.2%, p = 0.93) and Injury Severity Score of 16 or above (12.8% vs 14.9%, p = 0.40). The rate of tourniquet application was more than four-fold in the post-intervention period compared to the pre-intervention period (22.8% vs 5.5%, p < 0.001). Nevertheless, rates of in-hospital amputations (1.6% vs 1.6%, p = 1.00) and death (0.9% vs 1.3%, p = 0.53) were similar in the two periods.

CONCLUSION

Following the IDF military-wide introduction of advanced tourniquets, the tourniquet application rate rose sharply, the use of old tourniquets ceased over time, and in-hospital amputation rate did not increase. These findings suggest that the awareness for haemorrhage control using advanced tourniquets rose.

Assessing the Current Generation of Tourniquets

INTRODUCTION

Tourniquet application is an urgent life-saving procedure. Previous studies demonstrated several drawbacks in tourniquet design and application methods that limit their efficacy; among them, loose application of the device before windlass twisting is a main pitfall. A new generation of modern combat tourniquets was developed to overcome these pitfalls. The objective of this study was to assess the effectiveness of three new tourniquet designs: the CAT Generation 7 (CAT7), the SAM Extremity Tourniquet (SAM-XT), and the SOF Tactical Tourniquet Wide (SOFTT-W) as well as its correlation to the degree of slack.

MATERIALS AND METHODS

The three tourniquet models were applied in a randomized sequence on a HapMed leg tourniquet trainer, simulating an above-the-knee traumatic amputation by 60 military medicine track cadets. Applied pressure, hemorrhage control status, time until the bleeding stopped, estimated blood volume loss, and slack were measured.

RESULTS

The mean (±SD) pressure applied using the SAM-XT (186 mmHg ±63) or the CAT7 (175 mmHg ±79) was significantly higher compared to the pressure applied by the SOFTT-W (104 mmHg ±101, P < 0.017), with no significant difference between the first two (P > 0.05). Hemorrhage control rate was similar (P > 0.05) with SAM-XT (73.3%) and CAT7 (67.7%), and both were significantly better than the SOFTT-W (35%, P < 0.017). Slack was similar between CAT7 and SAM-XT (5.2 mm ± 3.4 vs. 5 mm ± 3.5, P > 0.05), yet significantly lower compared to the SOFTT-W (9 mm ± 5, P < 0.017). A strong negative correlation was found between slack and hemorrhage control rate (3.2 mm ± 1.5 mm in success vs. 10.5 mm ± 3.4 mm in failure, P < 0.001) and applied pressure (Pearson's correlation coefficient of -0.83, P < 0.001).

CONCLUSIONS

Both SAM-XT and CAT7 demonstrated a better pressure profile and hemorrhage control rate compared to SOFTT-W, with no significant difference between the two. The better outcome measures were strongly correlated to less slack.

[Prehospital application of tourniquets for life-threatening extremity hemorrhage : Systematic review of literature]

INTRODUCTION

The effectiveness of a tourniquet in the case of life-threatening hemorrhages of the extremities is well recognized and led to the recommendations on "Tourniquet" of the German Society of Anaesthesiology and Intensive Care (DGAI) in 2016. The aim of this systematic review was to re-evaluate the current medical literature in relation to the published DGAI recommendations.

MATERIAL AND METHODS

Based on the analysis of all studies published from January 2015 until January 2018 in the PubMed databases, the publicized recommendations for action on "Tourniquet" of the DGAI were critically re-evaluated. For this purpose, 17 questions on 6 subjects were formulated in advance. The systematic review followed the PRISMA recommendations and is registered in PROSPERO (International prospective register of systematic reviews, Reg.-ID: CRD42018091528).

RESULTS

Of the 284 studies identified with the keywords tourniquet and trauma in the period from January 2015 to January 2018 in PubMed, 50 original papers discussing the prehospital application of tourniquet for life-threatening hemorrhage of the extremities were included. The overall level of evidence is low. No article addressed any of the formulated questions with a prospective randomized interventional study. Scientific deductions could be found only in an indirect way in a descriptive manner.

CONCLUSION

The 50 original articles included in this qualitative, systematic review revealed that the recommendations "Tourniquet" of the DGAI published in 2016 are mostly still up to date despite an inhomogeneous study situation. A deviation occurred in the conversion of a tourniquet but due to the short prehospital treatment time in the civilian setting this is of little importance; however, in the future a strict distinction should be made between tourniquets which were placed for tactical reasons and those placed as a medical necessity.

The effect of prehospital transport time, injury severity, and blood transfusion on survival of US military casualties in Iraq

BACKGROUND

Reducing time from injury to care can optimize trauma patient outcomes. A previous study of prehospital transport of US military casualties during the Afghanistan conflict demonstrated the importance of time and treatment capability for combat casualty survival.

METHODS

A retrospective descriptive analysis was conducted to analyze battlefield data collected on US military combat casualties during the Iraq conflict from March 19, 2003, to August 31, 2010. All casualties were analyzed by mortality outcome (killed in action, died of wounds, case fatality rate) and compared with Afghanistan conflict. Detailed data for those who underwent prehospital transport were analyzed for effects of transport time, injury severity, and blood transfusion on survival.

RESULTS

For the total population, percent killed in action (16.6% vs. 11.1%), percent died of wounds (5.9% vs. 4.3%), and case fatality rate (10.0 vs. 8.6) were higher for Iraq versus Afghanistan (p < 0.001). Among 1,692 casualties (mean New Injury Severity Score, 22.5; mortality, 17.6%) with detailed data, the injury mechanism included 77.7% from explosions and 22.1% from gunshot wounds. For prehospital transport, 67.6% of casualties were transported within 60 minutes, and 32.4% of casualties were transported in greater than 60 minutes. Although 97.0% of deaths occurred in critical casualties (New Injury Severity Score, 25-75), 52.7% of critical casualties survived. Critical casualties were transported more rapidly (p < 0.01) and more frequently within 60 minutes (p < 0.01) than other casualties. Critical casualties had lower mortality when blood was received (p < 0.01). Among critical casualties, blood transfusion was associated with survival irrespective of transport time within or greater than 60 minutes (p < 0.01).

CONCLUSION

Although data were limited, early blood transfusion was associated with battlefield survival in Iraq as it was in Afghanistan.

LEVEL OF EVIDENCE

Performance improvement and epidemiological, level IV.

Sweating the Little Things: Tourniquet Application Efficacy in Two Models of Pediatric Limb Circumference

BACKGROUND

Current military recommendations include the use of tourniquets (TQ) in appropriate pediatric trauma patients. Although the utility of TQs has been well documented in adult patients, the efficacy of TQ application in pediatric patients is less clear. The current study attempted to identify physical constraints for TQ use in two simulated pediatric limb models.

METHODS

Five different TQ (Combat Application Tourniquet (CAT) Generation 6 and Generation 7, SOFTT (SOF Tactical Tourniquet), SOFTT-W (SOF Tactical Tourniquet - Wide), SWAT-T (Stretch Wrap and Tuck - Tourniquet) and a trauma dressing were evaluated in two simulated pediatric limb models. Model one employed four cardiopulmonary resuscitation (CPR) manikins simulating infant (Simulaids SaniBaby), 1 year (Gaumard HAL S3004), and 5 years (Laerdal Resusci Junior, Gaumard HAL S3005). Model two utilized polyvinyl chloride (PVC) piping with circumferences ranging from 4.25" to 16.5". Specific end-points included tightness of the TQ and ability to secure the windlass (where applicable).

RESULTS

In both models, the ability to successfully apply and secure the TQ depended upon the simulated limb circumference. In the 1-year-old CPR manikin, all windlass TQs failed to tighten on the upper extremity, while all TQs successfully tightened at the high leg and mid-thigh. With the exception of the CAT7 and the SOFTT-W at the mid-thigh, no windlass TQ was successfully tightened at any extremity location on the infant. The SWAT-T was successfully tightened over all sites of all CPR manikins except the infant. No windlass TQ was able to tighten on PVC pipe 5.75" circumference or smaller (age < 24 months upper extremity). All windlass TQs were tightened and secured on the 13.25" and 15.5" circumference PVC pipes (age 7-12 years lower extremity, age >13 years upper extremity). The SWAT-T was tightened on all PVC pipes.

DISCUSSION

The current study suggests that commercial windlass TQs can be applied to upper and lower extremities of children aged 5 years and older at the 50%th percentile for limb circumference. In younger children, windlass TQ efficacy is variable. Further study is required to better understand the limitations of TQs in the youngest children, and to determine actual hemorrhage control efficacy.

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.

Tourniquet use is not associated with limb loss following military lower extremity arterial trauma

BACKGROUND

The effect of battlefield extremity tourniquet (TK) use on limb salvage and long-term complications following vascular repair is unknown. This study explores the influence of TK use on limb outcomes in military lower extremity arterial injury.

METHODS

The study database includes cases of lower extremity vascular injury from 2004 to 2012 with data recorded until discharge from military service. We analyzed all limbs with at least one named arterial injury from the femoral to the tibial level. Tourniquet (TK) and no TK (NTK) groups were identified. Univariate analyses were performed with significance set at p ≤ 0.05.

RESULTS

A total of 455 cases were included, with 254 (56%) having a TK for a median of 60 minutes (8-270 minutes). Explosive injuries (53%) and gunshot wounds (26%) predominated. No difference between TK and NTK was present in presence of fracture, level of arterial injury, type of arterial repair, or concomitant venous injury. More nerve injuries were present in the TK group, and Abbreviated Injury Scale extremity and Mangled Extremity Severity Score tended toward greater injury severity. Amputation and mortality rates did not differ between groups, but the incidence of severe edema, wound infection, and foot drop was higher in the TK group. Vascular above-knee amputation, arterial repair complication, and severe edema were higher in the TK group also (p = 0.10). Tourniquet duration of 60 minutes or longer was not associated with increased amputations, but more rhabdomyolysis was present.

CONCLUSION

Field TK use is associated with wound infection and neurologic compromise but not limb loss. This may be due to a more severe injury profile among TK limbs. Increased TK times may predispose to systemic, but not limb, complications.

LEVEL OF EVIDENCE

Therapeutic/care management, level IV.

Effect of prehospital tourniquets on resuscitation in extremity arterial trauma

Background

Timely tourniquet placement may limit ongoing hemorrhage and reduce the need for blood products. This study evaluates if prehospital tourniquet application altered the initial transfusion needs in arterial injuries when compared with a non-tourniquet control group.

Methods

Extremity arterial injuries were queried from our level I trauma center registry from 2013 to 2017. The characteristics of the cohort with prehospital tourniquet placement (TQ+) were described in terms of tourniquet use, duration, and frequency over time. These cases were matched 1:1 by the artery injured, demographics, Injury Severity Score, and mechanism of injury to patients arriving without a tourniquet (TQ-). The primary outcome was transfusion within the first 24 hours, with secondary outcomes of morbidity (rhabdomyolysis, renal failure, compartment syndrome), amputation (initial vs. delayed), and length of stay. Statistical tests included t-test and χ² for continuous and categorical variables, respectively, with p<0.05 considered as significant.

Results

Extremity arterial injuries occurred in 192 patients, with 69 (36%) having prehospital tourniquet placement for an average of 78 minutes. Tourniquet use increased over time from 9% (2013) to 62% (2017). TQ+ patients were predominantly male (81%), with a mean age of 35.0 years. Forty-six (67%) received blood transfusion within the first 24 hours. In the matched comparison (n=69 pairs), TQ+ patients had higher initial heart rate (110 vs. 100, p=0.02), frequency of transfusion (67% vs. 48%, p<0.01), and initial amputations (23% vs. 6%, p<0.01). TQ+ patients had increased frequency of initial amputation regardless of upper (n=43 pairs) versus lower (n=26 pairs) extremity involvement; however, only upper extremity TQ+ patients had increased transfusion frequency and volume. No difference was observed in morbidity, length of stay, and mortality with tourniquet use.

Discussion

Tourniquet use has increased over time in patients with extremity arterial injuries. Patients having prehospital tourniquets required a higher frequency of transfusion and initial amputation, without an increase in complications.

Level of evidence

Therapeutic study, level IV.

Combat vascular injury: Influence of mechanism of injury on outcome

BACKGROUND

Haemorrhage is the leading cause of death on the battlefield. Seventy percent of injuries are due to explosive mechanisms. Anecdotally, these patients have had poorer outcomes when compared to those with penetrating mechanisms of injury (MOI). We wished to test the hypothesis that outcomes following vascular reconstruction were worse in blast-injured than non blast-injured patients.

METHODS

Retrospective cohort study. British and American combat casualties with arterial injuries sustained in Iraq or Afghanistan (2003-2014) were identified from the UK Joint Theatre Trauma Registry (JTTR). Eligibility included explosive or penetrating MOI, with follow-up to UK hospital discharge, or death. Outcomes were mortality, amputation, graft thrombosis, haemorrhage, and infection. Statistical analysis was performed using Pearson Chi-Square test, t-tests, ANOVA or non-parametric equivalent, and survival analyses.

RESULTS

One hundred and fifteen patients were included, 80 injured by explosive and 35 by penetrating mechanisms. Evacuation time, ISS, number of arterial injuries, age and gender were comparable between groups. Seventy percent of arterial injuries resulted from an explosive MOI. The explosive injuries group received more blood products (p = 0.008) and suffered more regions injured (p < 0.0001). Early surgical interventions in both were ligation (n = 36, 31%), vein graft (n = 33, 29%) and shunting (n = 9, 8%). Mortality (n = 12, 10%) was similar between groups. Differences in limb salvage rates following explosive (n = 17, 53%) vs penetrating (n = 13, 76.47%) mechanisms approached statistical significance (p = 0.056). Nine (28%) vein grafted patients developed complications. No evidence of a difference in the incidence of vein graft thrombosis was found when comparing explosive with non-explosive cohorts (p = 0.154).

CONCLUSIONS

The recorded numbers of vein grafts following combat arterial trauma in are small in the JTTR. No statistically-significant differences in complications, including vein graft thrombosis, were found between cohorts injured by explosive and non-explosive mechanisms.

Stop the Bleed: Does the Training Work One Month Out?

The Stop the Bleed initiative empowers and trains citizens as immediate responders, to recognize and control severe hemorrhage. We sought to determine the retention of short-term knowledge and ability to apply a Combat Application Tourniquet (CAT) in 10 nonmedical personnel. A standard “Stop the Bleed” (Bleeding Control) course was taught including CAT application. Posttraining performance was assessed at 30 days using a standardized mannequin with a traumatic below-knee amputation. Technique, time, pitfalls, and feedback were all recorded. No participant had placed a CAT before the initial class. After the initial class, self-report by a Likert scale survey revealed an increased confidence in tourniquet application from 2.4 pretraining to 4.7 posttraining. At 30 days, confidence decreased to 3.4 before testing. Six of 10 were successful at tourniquet placement. Completion time was 77.75 seconds (43–157 seconds). Successful participants reported a confidence level of 4.7 versus those unsuccessful at 3.3. The “Stop the Bleed” initiative teaches lifesaving skills to the public through a short training course. This information regarding the training of nonmedical personnel may assist in strengthening training efforts for the public. Further investigations are needed to characterize skill degradation and retention over time.

En Route Critical Care Transfer From a Role 2 to a Role 3 Medical Treatment Facility in Afghanistan

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.

Effects of Tactical Emergency Casualty Care Training for Law Enforcement Officers

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.

Bleeding Control With Limb Tourniquet Use in the Wilderness Setting: Review of Science

The purpose of this review is to summarize tourniquet science for possible translation to wilderness settings. Much combat casualty data has been studied since 2005, and use of tourniquets in the military has changed from a last resort to first aid. The US Government has made use of tourniquets a health policy aimed to improve public access to bleeding control items. International authorities believe that education in first aid should be universal, as all can and should learn first aid. The safety record of tourniquet use is mixed, but users are reliably safe if trained well. Well-designed tourniquets can reliably attain bleeding control, may mitigate risk of shock progression, and may improve survival rates, but conclusive proof of a survival benefit remains unclear in civilian settings. Even a war setting has a bias toward survivorship by sampling mostly survivors in hospitals. Improvised tourniquets are less reliable than well-designed tourniquets but may be better than none. The tourniquet model used most often in 2016 by the US military is the Combat Application Tourniquet (C-A-T), and civilians use an array of various models, including C-A-T. Evidence on tourniquet use to date indicates that most uses are safe and effective in civilian settings. Future directions for study relevant to the wilderness setting include consideration of research priorities, study of the burdens of injury or capability gaps in caregiving for various wilderness settings, determination of the skill needs of outdoor enthusiasts and wilderness caregivers, and survey of wilderness medicine stewards regarding bleeding control.

Penetrating Vascular Injury: Diagnosis and Management Updates

Penetrating vascular injury is becoming increasingly common in the United States and abroad. Much of the current research and treatment is derived from wartime and translation to the civilian sector has been lacking. Penetrating vascular injury can be classified as extremity, junctional, or noncompressible. Diagnosis can be obvious but at other times subtle and difficult to diagnose. Although there are numerous modalities, computed tomography angiography is the diagnostic study of choice. It is hoped that care will be improved by using an algorithmic approach integrating experience from military and civilian research.

Leadership and a casualty response system for eliminating preventable death

Combat casualties who die from their injuries do so primarily in the prehospital setting. Although most of these deaths result from injuries that are nonsurvivable, some are potentially survivable. Of injuries that are potentially survivable, most are from hemorrhage. Thus, military organizations should direct efforts toward prehospital care, particularly through early hemorrhage control and remote damage control resuscitation, to eliminate preventable death on the battlefield. A systems-based approach and priority of effort for institutionalizing such care was developed and maintained by medical personnel and command-directed by nonmedical combatant leaders within the 75th Ranger Regiment, U.S. Army Special Operations Command. The objective of this article is to describe the key components of this prehospital casualty response system, emphasize the importance of leadership, underscore the synergy achieved through collaboration between medical and nonmedical leaders, and provide an example to other organizations and communities striving to achieve success in trauma as measured through improved casualty survival.

There's an app for that: A handheld smartphone-based infrared imaging device to assess adequacy and level of aortic occlusion during REBOA

BACKGROUND

Advances in thermal imaging devices have made them an appealing noninvasive point-of-care imaging adjunct in the trauma setting. We sought to assess whether a smartphone-based infrared imaging device (SBIR) could determine presence and location of aortic occlusion in a swine model. We hypothesized that various levels of aortic occlusion would transmit significantly different heat signatures at various anatomical points.

METHODS

Six swine (35-50 kg) underwent sequential zone 1 (Z1) aortic cross clamping as well as zone 3 (Z3) aortic balloon occlusion (resuscitative endovascular balloon occlusion of the aorta [REBOA]). SBIR images and readings (FLIR One) were taken at five anatomic points (axilla [A], subcostal [S], umbilical [U], inguinal [I], medial malleolar [M]) and were used to determine significant thermal trends 5 minutes to 10 minutes after Z1 and Z3 occlusion. Significant (p ≤ 0.05) thermal ratio patterns were identified and compared among groups, and images were reviewed for obvious qualitative differences at the various levels of occlusion.

RESULTS

Body temperatures were similar during control (CON), Z1 occlusion, and Z3 occlusion, ranging from 94.0 °F to 100.9 °F (p = 0.126). No significant temperature differences were found among A, S, U, I, M points prior to and after aortic occlusions. Among the anatomical 2-point ratios evaluated, A/M and S/M ratios were the best predictors of aortic occlusion, whether at Z1 (8.2 °F, p < 0.01; 10.9 °F, p < 0.01) or Z3 (7.3 °F, p < 0.01; 8.4 °F, p < 0.01), respectively. The best predictor of Z1 versus Z3 level of occlusion was the S/I ratio (5.2 °F, p < 0.05 vs. 3.4 °F, p = 0.27). SBIR generated qualitatively different thermal signatures among groups.

CONCLUSION

SBIR was capable of detecting thermal trends during Z1 and Z3 aortic occlusion by using an anatomical 2-point thermal ratio. There were also easily recognized qualitative differences between control and occlusion images that would allow immediate determination of adequate occlusion of the aorta. SBIR represents a potential inexpensive and accurate tool for assessing perfusion, adequate REBOA placement, and even the aortic level of occlusion.

Trends and Predictors of Limb Tourniquet Use by Civilian Emergency Medical Services in the United States

BACKGROUND

Tourniquet use by Emergency Medical Services (EMS) can be life saving for severely injured patients. The adoption of this intervention is not well described in civilian settings. This study describes patterns and trends of tourniquet use by civilian EMS and identifies predictors of such use.

METHODS

A retrospective study of four consecutive releases of the U.S. National Emergency Medical Services Information System (NEMSIS) public research dataset (2011-14) was conducted. Descriptive analysis was performed to compare two groups of EMS activations for injuries with or without tourniquet application. This was followed by multivariate logistic regression to identify predictors of tourniquet use.

RESULTS

A total of 2,048 tourniquet applications were documented among all EMS activations for injured patients (N = 10,366,537) yielding a prevalence of 0.2 per 1,000 EMS activations. Tourniquets were mainly applied in young (mean age 44.0 ± 21.1 years) male patients (76.5%) in urban and suburban EMS activations (86.4%) and by advanced life support (ALS) EMS services (81.6%). Most common complaints reported by dispatch for EMS activations with tourniquet use were Traumatic injury (25.3%), Hemorrhage/laceration (23.5%), and Traffic accident (16.8%) with injuries mainly related to Stabbing/Accidental cutting (20.3%), Falls (17.1%), and Motor vehicle traffic accident (11.5%). Upper extremity injuries (39.6%) were more common than Lower extremity injuries (27.3%). The providers' primary impression was predominantly Traumatic injury (92.8%), and patients' primary symptoms were mainly Bleeding (50.4%) and Wound (28.7%). All prehospital time intervals except on-scene time interval were significantly shorter in the group with tourniquets compared to the group without tourniquets (p < 0.05). Reported prevalence of tourniquet use by EMS (per 1,000 EMS injury activations) increased from 2011 to 2012 then stabilized over the following years (2012-14). Significant predictors of tourniquet use reported by the provider were identified and included demographic characteristics, EMS agency type, specific complaints, injury cause, injury anatomic location, chief complaint organ system, and primary symptom.

CONCLUSION

Reported tourniquet use by EMS for injured patients in the U.S. is low. Increasing adoption mainly by urban services was noted. Predictors for tourniquet use in civilian trauma were identified. Establishing the effectiveness of this intervention by comparing patient outcomes is needed. Key words: emergency medical services; prehospital; tourniquet; injury; NEMSIS; hemorrhage.

US service member tourniquet use on the battlefield: Iraq and Afghanistan 2003–2011

Introduction

Tourniquet use has not been studied regarding specifically combat-intense military occupational specificities. This analysis examined the survivability, frequency of use, and nature of injuries in which tourniquets were employed among personnel in a single combat-specific military occupational specialty during combat operations.

Methods

Injuries sustained by the combat-specific soldier, the cavalry scout, from 2003 to 2011 were identified using the Joint Theater Trauma Registry. Basic demographic information, mechanism of injury, injury characteristics, and mortality were recorded.

Results

Of the 453 cavalry scouts wounded in action, 313 had adequate documentation upon arrival to a field hospital. Tourniquets were applied to 24 (7.7%) extremity wounds, 23 (96%) of these soldiers survived and one died of wounds (4.2%). Among those is in which tourniquets were used, there were seven (30%) senior enlisted and 16 (70%) junior enlisted soldiers with an average age of 24.8 years. Injuries were caused by gunshot wounds in 4 (17%), explosions in 18 (74%) and other mechanisms in two (8.3%). The primary reason for tourniquet application was open fracture ( n = 14, 61%), followed by vascular injury ( n = 5, 22%), and amputation ( n = 3, 13%). Other penetrating injuries were present in 19 (83%) of scouts.

Conclusion

The high survivability of patients transported with tourniquet in place underscores the importance of battlefield tourniquet application. Continued focus on education and equipping combat personnel with tourniquets is critical to survivability of the injured solider.

A hybrid simulator model for the control of catastrophic external junctional haemorrhage in the military environment

Catastrophic haemorrhage from extremity injuries has for a long time been the single most common cause of preventable death in the military environment. The effective use of extremity tourniquets has increased the survival of combat casualties, and exsanguination from isolated limb injuries is no longer the most common cause of death. Today, the most common cause of potentially preventable death is haemorrhage from the junctional zones, i.e. the most proximal part of the extremities, not amenable to standard tourniquets.

Different training techniques to control catastrophic haemorrhage have been used by the Swedish Armed Forces in the pre-deployment training of physicians, nurses and medics for many years. The training techniques include different types of human patient simulators such as moulage patients and manikins. Preferred training conditions for the control of catastrophic haemorrhage include a high degree of realism, in combination with multiple training attempts.

This report presents a new hybrid training model for catastrophic external junctional haemorrhage control. It offers a readily reproducible, simple and inexpensive opportunity to train personnel to deal with life threatening catastrophic junctional haemorrhage. In particular, this model offers an opportunity for non-medical military personnel in Sweden to practice control of realistic catastrophic haemorrhage, with multiple training attempts.

Ballistic trauma: lessons learned from iraq and afghanistan

Management of upper extremity injuries secondary to ballistic and blast trauma can lead to challenging problems for the reconstructive surgeon. Given the recent conflicts in Iraq and Afghanistan, advancements in combat-casualty care, combined with a high-volume experience in the treatment of ballistic injuries, has led to continued advancements in the treatment of the severely injured upper extremity. There are several lessons learned that are translatable to civilian trauma centers and future conflicts. In this article, the authors provide an overview of the physics of ballistic injuries and principles in the management of such injuries through experience gained from military involvement in Iraq and Afghanistan.