Military trauma

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Lessons for ED staff from the military management of severe trauma

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Military trauma

  1. 1. Why? ●A short history of military medicine –Changing battlefields –EBM, Better data sets –Save before you can fix –Resource constraints ●Drive to more efficient care ●Reduce Longterm dependancy
  2. 2. Goal To perform the correct intervention at the correct time in the continuum of Care to improve survival and reduce morbidity. In other words, a medically correct intervention performed at the wrong time in the military continuum of care may lead to further casualties or worse outcomes
  3. 3. Factors influencing combat casualty care ●Enemy Fire ●Medical Equipment Limitations ●Widely Variable Evacuation Time ●Tyranny of numbers
  4. 4. Principles of TCCC • The three goals of Tactical Combat Casualty Care (TCCC) are: –1. Save preventable deaths –2. Prevent additional casualties –3. Complete the mission
  5. 5. Development Physiology Of trauma Principles of trauma care Risk tolerance Principles of TCCC Trauma registry Care pathway
  6. 6. How
  7. 7. Forensics
  8. 8. Improvisation
  9. 9. Mid tour christmas Party
  10. 10. Parasitology
  11. 11. Ground Ambulance
  12. 12. MASH
  13. 13. WHO? ●Changing patient –The 90/10 rule ●WW1 90% mil 10% Civ, ●OIF/OEF 90% Civ 10% Mil ●Historically 90% non battle casualties (disease predominantly) ●Modern conflicts 90% battle casualties
  14. 14. Monthly Admissions by Facility 0 50 100 150 200 250 300 350 Bagram Kandahar Bastion Dwyer Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 8/17/2014 8 Right Patient, Right Care, Right Place, Right Time
  15. 15. OEF Total Trauma Admissions Battle vs. Non-Battle Injury 385 572 725 743 722 627 589 477 348 348 302 448 126 93 120 117 111 87 83 110 126 130 114 150 0 100 200 300 400 500 600 700 800 900 1000 Apr- 10 May- 10 Jun- 10 Jul-10 Aug- 10 Sep- 10 Oct- 10 Nov- 10 Dec- 10 Jan- 11 Feb- 11 Mar- 11 Battle vs. Non-Battle Injury – 1 Year Non-Battle (25%) Battle (75%) 8/17/2014 12 Right Patient, Right Care, Right Place, Right Time
  16. 16. How - Cause of Injury Mar 2011 148 10 23 6 249 7 17 2 14 63 9 44 Bullet/GSW/Firearm Burn Fall Hand Grenade IED Knife/Other Sharp Object Machinery/Equipment Mine/Landmine Mortar/Rocket/Artillery Shell MVC RPG Other 8/17/2014 36 Right Patient, Right Care, Right Place, Right Time ncludes both battle and non-battle injury
  17. 17. Trauma and The Lethal Triad Acidosis Hypothermia Coagulopathy Death Brohi, K, et al. J Trauma, 2003.
  18. 18. Combat Deaths •KIA: 31% Penetrating head trauma •KIA: 25% Surgically uncorrectable torso trauma •KIA: 10% Potentially surgically correctable trauma •KIA: 9% Hemorrhage from extremity wounds •KIA: 7% Mutilating blast trauma •KIA: 5% Tension pneumothorax •KIA: 1% Airway problems •12% Mostly from infections and complications of shock
  19. 19. PREVENTABLE CAUSES OF COMBAT DEATH •60% Hemorrhage from extremity wounds •33% Tension pneumothorax •6% Airway obstruction e.g., maxillofacial trauma •* Data is extrapolated from Vietnam to present day Iraq and Afghanistan
  20. 20. Survival 80% survive 70% survive at 1 hour 60% survive to 24 hours 50% survive to 72 hours 20% die immediately 10% die over the first hour – Hg/Airway Further 10% die by 6 hours – lethal triad 10% die over the next 48 hours – lethal triad and late complications
  21. 21. Summary • There are three categories of casualties on the battlefield: 1. Operators who will live regardless 2. Operators who will die regardless 3. Operators who will die from preventable deaths unless there is intervention • Target the intervention to the mechanism and time window
  22. 22. CMAST 43 Injury severity
  23. 23. OEF Shock on Admission (BD > 5) 0 20 40 60 80 100 120 140 OEF Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 13.3% of total OEF admissions 8/17/2014 18 Right Patient, Right Care, Right Place, Right Time 1-Year’s Data: Apr 10– Mar 11
  24. 24. OEF Hypothermia Breakdown 7 2 27 0 5 10 15 20 25 30 35 40 US Military Coalition All Others Admission Temperature < 96 F or < 35.5 C Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 1% of all US admissions .3% of all Coalition admissions 8/17/2014 17 Right Patient, Right Care, Right Place, Right Time 4.5% of all Others admissions
  25. 25. OEF Total Casualties Requiring Blood 0 20 40 60 80 100 120 140 NumberofAdmissions (2050/7758= 26.4%) US Mil 32% (N=663) Coalition 11% (N=225) Others 57% (N=1161) 8/17/2014 20 Right Patient, Right Care, Right Place, Right Time
  26. 26. Massive Transfusion Component Therapy 0 5 10 15 20 25 30 18.2 18.7 3.2 3.1 21 Mar 2011 MT Patients (N= 49) Mean # units transfused Mean RBC Age Platelets: 1 unit = 6 pk plts 8/17/2014 25 Right Patient, Right Care, Right Place, Right Time Total Units FWB: 0 Doses of Factor VII: 1 (Level III Only)
  27. 27. OEF Level III Massive Transfusion Survival 70% 75% 80% 85% 90% 95% 100% 0 20 40 60 80 100 120 140 2nd Qtr 10 3nd Qtr 10 4th Qtr 10 1st Qtr 11 %Survival #MassiveTransfusions # Massive Transfusions % Survival 8/17/2014 23Right Patient, Right Care, Right Place, Right Time
  28. 28. OEF Massive Transfusion Survival Long Term US Military Only 70% 75% 80% 85% 90% 95% 100% 0 10 20 30 40 50 60 70 2nd Qtr 10 3rd Qtr 10 4th Qtr 10 1st Qtr 11 %Survival #MassiveTransfusions # Massive Transfusions % Survival 8/17/2014 18 Right Patient, Right Care, Right Place, Right Time
  29. 29. OEF Massive Transfusion Survival Long Term Coalition Only 70% 75% 80% 85% 90% 95% 100% 0 10 20 30 40 50 60 70 2nd Qtr 10 3rd Qtr 10 4th Qtr 10 1st Qtr 11 %Survival #MassiveTransfusions # Massive Transfusions % Survival 8/17/2014 24 Right Patient, Right Care, Right Place, Right Time
  30. 30. More Complicated Than Anticipated – Acute Coagulopathy of Trauma Shock 25% of trauma patients present coagulopathic
  31. 31. WHERE Platform agnostic When is crucial to outcome, where is not.
  32. 32. Putting it all together
  33. 33. Concept of Medical Support FAST FIX 6 – 24 hours 80% STABILISE 1 Hour 3% surgical RESUSCITATE 15 Minutes 100% SAVE 5 Minutes 100% Fd Hosp FSSD FASTBuddy Aid CLS Point of injury Forward casualty Circulation Rear casualty Circulation 17% Return to duty 72 hours SMART
  34. 34. Questions?

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