Holley: WAR - What is it good for?


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Anthony Holley brings a military perspective to advances made in trauma management on and off the battlefield.

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  • Good morning Colleagues Thank you to the organising committee for the opportunity to be here.
  • Good morning Colleagues Thank you to the organising committee for the opportunity to be here.
  • War and Medicine seeks to understand the complex relationship between medical advances and armed conflict. As nations have developed increasingly sophisticated weaponry with which to harm theirs enemies, medicine has had to adapt to cope with the volume and changing nature of the resulting casualties. Many of the lessons learned in wartime have prompted advances in medicine and in social policy away from the battlefield. However, arguments about whether the relationship between war and medicine serves to further the progress of medical research or to hinder its proper evolution are far from settled. This volume brings together enquiries from all aspects of human culture in a fascinating contribution to this continuing debate. War and Medicine draws on formal investigation but also on the personal testimonies of surgeons, soldiers, civilians, nurses, writers and artists to address the moral, ethical and philosophical dilemmas faced by those charged with the administration of medicine in times of war. Published in conjunction with the exhibition of the same name, organised by Wellcome Collection and the Deutsches Hygiene Museum, Dresden, War and Medicine is an important and timely book.
  • he Civil War created both crises and opportunities never before imagined by the medical professional. Doctors of the time were not prepared to deal with the staggering number and nature of wounds inflicted. And often, absolute necessity mothered many inventions, from new surgical instruments to the logistics of providing ambulance service on the battlefield. The brutal reality of the war pushed doctors to a new level of medical and surgical knowledge. In Civil War medicine 1861-1865, Dr. C. Keith Wilbur takes you on a detailed and fascinating tour through the medical history of this bloody and devastating war. Hundreds of illustrations, combined with well-researched and engaging text, tell the tale of the challenges presented to physicians with each new battle and the often-heroic ways those challenges were met. Discover and learn: how outmoded theories hobbled doctors in the field; the stories of the women who first entered a 'man's army' as nurses; the details about the field hospitals, from the different kinds of bandages used to the diseases and wounds the doctors treated; and details of the day's surgical practices, medications, and anesthesia (or lack thereof). There is nothing that war has ever achieved that we could not better achieve without it.  ~Havelock Ellis
  • Iraq and Afghanistan have introduced new concepts and understanding in the field of trauma. Efforts to understand patterns of injury and care evolved from case reports/case series. First ever formal combat Trauma registry within a theater trauma system. First time dedicated trauma research teams deployed in theatre charged with performing and facilitating research activities. System and trauma research provided a framework to develop clinical practice guidelines, and track clinical outcomes after implementation.
  • war which lasted twenty-two years with a short interval until the defeat of the French at Waterloo in 1815. It was- during this campaign of the Rhine that Larrey, painfully impressed by the utter lack of system in caring for the wounded, conceived the idea of organized effort on military lines to give immediate and adequate succour to the victims of battles. Usually the wounded remained where they fell until fighting was over, rarely receiving surgeons' attention until twenty-four hours had passed. In cases of defeat they were abandoned. Larrey decided the surgeon ought to go to the wounded, and that aid must be a matter of routine and administered with the same status as any other military measure. He deemed the hospital provisions,
  • Iraq and Afghanistan have introduced new concepts and understanding in the field of trauma. Efforts to understand patterns of injury and care evolved from case reports/case series. First ever formal combat Trauma registry within a theater trauma system. First time dedicated trauma research teams deployed in theatre charged with performing and facilitating research activities. System and trauma research provided a framework to develop clinical practice guidelines, and track clinical outcomes after implementation
  • The Joint Theater Trauma System (JTTS) is an organized approach to providing improved trauma care across the continuum of the Levels of Care to trauma patients, especially in the battlefield environment. The Joint Theater Trauma Registry (JTTR) is the data repository collecting and hosting all DoD trauma related data. The mission of the JTTS is to: Establish and maintain a Department of Defense Trauma Registry System to capture data and provide information on care and outcomes of military and civilian trauma patients. Provide the Department of Defense and other authorized interests with timely and relevant information about care and outcomes of military and civilian injuries. Create a research strategy that supports reduction of morbidity and mortality in military and civilian trauma patients. Establish and maintain a trauma outcomes database to analyze and evaluate clinical decision making and measure subsequent outcomes for improving treatment modalities. Provide activities of each of the services with full and complete access to data resident in the DoD Trauma Registry. The goals of the JTTS include: Provide the ability to perform data driven battlefield level process improvement of trauma care that drives morbidity and mortality to lowest possible levels. Expand across DoD to bring trauma systems into fixed facility care as well as theater care thus enhancing readiness to provide optimal trauma care to deployed Service members. Emphasize continuous improvement in medical record documentation quality. Capture and share patient data across all levels of care to enable evaluation and adherence to theater clinical practice guidelines and standard operating procedures (SOPs). Identify training requirements, capture injury epidemiology, support research initiatives, and assess success of interventions and outcomes.
  • It must be recognized that wartime clinical decision making can be challenging. Triage is especially difficult for medical providers accustomed to caring for patients in medical centers in the United States, where there are adequate resources, manpower, and other hospitals nearby. In a war environment, decisions have to be made based on different expectations: several severely injured patients will arrive simultaneously, providers are few, critical resources (such as operating rooms, CT scanners, and blood products) are limited, and evacuation assets may be unavailable. The goal of proper triage is to use limited resources to help the largest number of patients (3). EVALUATION OF MILITARY GUIDELINES IN THE CIVILIAN ARENA The process described herein is not unique, and existed in some form during World War II and Vietnam. However, serious errors were made after those wars, with civilians blindly adopting the military guidelines into civilian practice. The classic example after World War II was mandatory colostomy for all colon wounds, which unfortunately resulted in thousands of unnecessary colostomies over the ensuing 50 years. Not until the 1980s, when randomized trials were finally performed, did practice change to a more balanced approach of primary repair for most colon wounds and selective colostomy for the most severe injuries.
  • In contrast to landmine or artillery injuries commonly seen in Vietnam, the IED is the signature mechanism of injury in OEF and OIF. Because of the contamination and soft-tissue injury caused by exploding ordnance, injuries from IEDs and other explosive armaments in Iraq and Afghanistan require a more aggressive treatment approach, especially when the individual is in proximity to the blast radius. The average IED releases compressed gas at up to 26,000 feet per second. The high-pressure blast waves can reach up to 1300 mph. The initial shock wave of very high pressure is followed closely by a huge volume of displaced air flooding back into the area, again under high pressure. The extreme differences in pressure result in nonpenetrating blast injuries such as severe concussive traumatic brain injuries (TBIs) and abdominal and pulmonary injuries.
  • The conflict in Afghanistan, as well as the recently concluded operations in Iraq, have involved adversaries who are typically limited in both finances and technological access. With the common use of improved body armor by United States forces, the enemies have moved away from the standard assault rifles and have resorted to improvised explosive devices as their weapon of choice. These makeshift bombs often employ explosives taken from unused land mines, artillery shells, and other weapons, and focus them upon dismounted personnel. This has led to an unprecedented wounding pattern in terms of massive trauma inflicted on individuals. Even in light of these devastating injuries, with markedly increased injury severity scores, when compared to previous conflicts, the survival rate of our injured troops is at an all-time high.
  • This is more recent data from Iraq and Afghanistan. Hemorrhage is still the major cause of potentially preventable deaths. J Trauma Acute Care Surg.  2012 Dec;73(6 Suppl 5):S431-7. doi: 10.1097/TA.0b013e3182755dcc. Death on the battlefield (2001-2011): implications for the future of combat casualty care. Eastridge BJ ,  Mabry RL ,  Seguin P ,  Cantrell J ,  Tops T ,  Uribe P ,  Mallett O ,  Zubko T ,  Oetjen-Gerdes L ,  Rasmussen TE ,  Butler FK ,  Kotwal RS ,  Holcomb JB ,  Wade C ,  Champion H ,  Lawnick M ,  Moores L ,  Blackbourne LH . Source US Army Institute of Surgical Research, Fort Sam Houston, Texas, USA. eastridge@uthscsa.edu Abstract BACKGROUND: Critical evaluation of all aspects of combat casualty care, including mortality, with a special focus on the incidence and causes of potentially preventable deaths among US combat fatalities, is central to identifying gaps in knowledge, training, equipment, and execution of battlefield trauma care. The impetus to produce this analysis was to develop a comprehensive perspective of battlefield death, concentrating on deaths that occurred in the pre-medical treatment facility (pre-MTF) environment. METHODS: The Armed Forces Medical Examiner Service Mortality Surveillance Division was used to identify Operation Iraqi Freedom and Operation Enduring Freedom combat casualties from October 2001 to June 2011 who died from injury in the deployed environment. The autopsy records, perimortem records, photographs on file, and Mortality Trauma Registry of the Armed Forces Medical Examiner Service were used to compile mechanism of injury, cause of injury, medical intervention performed, Abbreviated Injury Scale (AIS) score, and Injury Severity Score (ISS) on all lethal injuries. All data were used by the expert panel for the conduct of the potential for injury survivability assessment of this study. RESULTS: For the study interval between October 2001 and June 2011, 4,596 battlefield fatalities were reviewed and analyzed. The stratification of mortality demonstrated that 87.3% of all injury mortality occurred in the pre-MTF environment. Of the pre-MTF deaths, 75.7% (n = 3,040) were classified as nonsurvivable, and 24.3% (n = 976) were deemed potentially survivable (PS). The injury/physiologic focus of PS acute mortality was largely associated with hemorrhage (90.9%). The site of lethal hemorrhage was truncal (67.3%), followed by junctional (19.2%) and peripheral-extremity (13.5%) hemorrhage. CONCLUSION: Most battlefield casualties died of their injuries before ever reaching a surgeon. As most pre-MTF deaths are nonsurvivable, mitigation strategies to impact outcomes in this population need to be directed toward injury prevention. To significantly impact the outcome of combatcasualties with PS injury, strategies must be developed to mitigate hemorrhage and optimize airway management or reduce the time interval between the battlefield point of injury and surgical intervention.Understanding battlefield mortality is a vital component of the military trauma system. Emphasis on this analysis should be placed on trauma system optimization, evidence-based improvements in Tactical Combat Casualty Care guidelines, data-driven research, and development to remediate gaps in care and relevant training and equipment enhancements that will increase the survivability of the fighting force Tactical Combat Casualty Care (TCCC) 06/23/13 DRAFT
  • Tactical Combat Casualty Care (TCCC) 06/23/13 DRAFT COL Holcomb and his co-authors list TCCC as one of the major reasons for that success. Also kudos to the rest of the chain of care, from the Level II and III hospitals in theater, the evac crews, the staff at Landstuhl, all the way back to the staffs at Walter Reed and Bethesda.
  • After a century of minimal improvement, combat injury survival rates in OEF and OIF have been considerably higher than in previous wars. This improvement is due to many factors. Medical improvements play a significant role in the outcome improvement; these include rapid evacuation, improved trauma care, and surgical techniques and guidelines. By far, the single most influential factor is the improvement in body armor and its consistent and mandatory use. This was confirmed by the Armed Forces Institute of Pathology, which analyzes causes of deaths by the use of CT scans and autopsies, a procedure known as “virtual autopsy,” which began as a research program of the Defense Advanced Research Projects Agency (DARPA).To date, 100% of all deaths incurred as a result of combat have undergone virtual autopsy. The resultant database allows the type and mechanism of injuries to be studied in order to improve both personal protective gear and medical interventions on the battlefield. The considerable decrease in penetrating torso injuries exemplifies how effectively the improved body armor has saved lives.
  • Tactical Combat Casualty Care (TCCC) 06/23/13 DRAFT Prehospital care is the most important aspect in ensuring the survival of the casualty. If the casualty does not arrive alive at the Forward Surgical Team or the Combat Support Hospital, then the surgeon’s skill can’t help. There may not be any combat medical personnel available when the casualty occurs. Initial care may have to be provided by the combatant. The goal of TCCC is to identify and treat those casualties with preventable causes of death, and keep them alive long enough to reach the hospital.
  • Tactical Combat Casualty Care (TCCC) 06/23/13 DRAFT These are the training programs that are used to teach trauma care in the civilian community. They are all EXCELLENT training programs. However, they are designed for the civilian trauma setting - the principles they reflect often need to be modified for the tactical setting. Emerging civilian guidelines/programs are only recently beginning to address providing care in conjunction with an ongoing threat.
  • Tactical Combat Casualty Care (TCCC) 06/23/13 DRAFT These are our 3 phases of care in TCCC. Next we’ll define these three phases of care. The picture is an FA-18 flying by Mt. Fuji.
  • The pre-hospital/point of injury care is that which is provided to the wounded combatant from the time injury is inflicted, often under the pressures of ongoing combat, until the patient begins evacuation to a higher level of medical care. Primary areas of focus include the tending to the basics/essentials: A (airway), B (breathing), and C (circulation/hypotension/malperfusion). Combat experience has shown that utilizing a modified mnemonic, CABC, where the first C is control of catastrophic (and typically extremity) hemorrhage, is more practical. Changes during this period of care have focused on hemostasis (addressing catastrophic hemorrhage) as well as fluid resuscitation (addressing the second C, circulation) in the forward/battlefield setting.
  • Tactical Combat Casualty Care (TCCC) 06/23/13 DRAFT This report was written by an Army doctor in World War II. Provided very clear input on tourniquets. A tourniquet would seem to be a simple thing to fix. Now, fast-forward 25 years.
  • This paper on Special Ops deaths showed 3 out of 12 potentially preventable deaths were due to extremity hemorrhage. Note the makeshift tourniquets used here Three cases were identified in which the casualty had hemorrhaged from a site that was amenable to placement of a tourniquet. Two of these 3 had no tourniquet placed and 1 was a case of tourniquet failure. Lack of tourniquet use and tourniquet failure has been thoroughly investigated, followed by a major initiative to field the Combat Application Tourniquet tourniquet.19,20 This device was tested by U.S. Army Special Operations Command operators, and trauma surgeons and found to be superior in function and feasibility to the traditional “cravat and stick” used in the period of this study. Walters TJ, Wenke JC, Kauvar DS, et al. Effectiveness of self-applied tourniquets in human volunteers. Prehosp Emerg Care. 2005;9:416 – 422 Wenke JC, Walters TJ, Greydanus DJ, et al. Physiological evaluation of the U.S. Army one-handed tourniquet. Mil Med. 2005;170:776 –781.
  • Sentiment for the utility of tourniquets is spreading to the civilian sector, with the most recent advanced trauma life support recommendations endorsing their use in appropriate circumstances. By the end of 2012, tourniquets will be required on all basic life support ambulances.
  • DRAFT We were still losing people to extremity bleeding in 2004. Notice the makeshift tourniquets used here. At about this point, the military had started a very strong effort to push tourniquets forward. Since this study, preventable deaths from extremity hemorrhage have now been minimized due largely to issuing a new IFAK and training individuals to use it.
  • Summary of data from 2 studies of patients presenting to a combat hospital in Iraq with tourniquets placed for extremity trauma. Both documented high survival rates and low morbidities associated with placement (with major morbidities being nerve palsies at the tourniquet site and substantial limb shortening potentially due to tourniquet damage). These studies combined to show that early application (pre-hospital) had a superior survival, when compared to placement on arrival to a hospital facility (89% vs 78% hospital, P < .01). Additionally, there was a survival benefit noted when tourniquets were placed prior to the onset of shock (96% versus 4% survival when placed after the onset of shock). (Data from Reference 4.)
  • Abstract BACKGROUND: In a previous study conducted at a combat support hospital in Iraq, we reported the major lifesaving benefits of emergency tourniquets to stop bleeding in major limb trauma. Morbidity associated with tourniquet use was minor. STUDY OBJECTIVES: The objective of this study is to further analyze emergency tourniquet use in combat casualty care. DESIGN AND SETTING: This report is a continuation of our previous study of tourniquet use in casualties admitted to a combat support hospital (NCT00517166 at www.ClinicalTrials.gov). METHODS: After verifying comparable methodologies for the first study and the current study, we compared patient results for these two time periods and then pooled data to analyze outcomes with a larger sample size. RESULTS: The total study population was 499 (232 in the previous study and 267 in the current study). In all, 862 tourniquets were applied on 651 limbs. Survival was 87% for both study periods. Morbidity rates for palsies at the level of the tourniquet were 1.7% for study 1 and 1.5% for study 2; major limb shortening was 0.4% for both. Survival was associated with prehospital application (89% vs. 78% hospital, p < 0.01) and application before the onset of shock (96% vs. 4% after). CONCLUSIONS: This study shows consistent lifesaving benefits and low risk of emergency tourniquets to stop bleeding in major limb trauma. Published by Elsevier Inc.
  • FIGURE 2. A, Survival rates for patients with tourniquets used versus not used. The Kaplan-Meier survivorship graph shows that the 92% survival rate for the patients with tourniquets used is significantly higher than the 0% survival rate for those who had tourniquets not used ( P 0.001). Also, the times to death are longer for those with tourniquets used. Death without tourniquets used occurred within a few minutes to 2 hours of injury. In both groups, all deaths occurred within the first 21 days. See text for matching method for these patients with only limb injuries. The groups were matched for having limb injuries only, injury severity scores (ISS), and abbreviated injury scales (AIS). B, Survival rates for patients with tourniquets used with shock present versus absent at application time. The Kaplan-Meier survivorship graph shows that the 90% survival rate for the patients with tourniquets used when shock was absent at application time is significantly higher than the 10% survival rate for those who had tourniquet used when shock was present ( P 0.001). Also, the times to death are longer when shock was absent. The shock present group had a higher mean injury severity scores ( P 0.04). C, Survival rates for patients with tourniquets used prehospital versus ED. The Kaplan-Meier survivorship graph shows that the 89% survival rate for the patients with tourniquets used prehospital is significantly higher than the 76% survival rate for those who had a tourniquet first used on a limb in the emergency department (ED; P 0.05). Also, the average time to death is longer with those with tourniquet used prehospital. The mean injury severity scores of the 2 groups were similar ( P 0.6). Abstract OBJECTIVE: The purpose of this study was to determine if emergency tourniquet use saved lives. SUMMARY BACKGROUND DATA: Tourniquets have been proposed as lifesaving devices in the current war and are now issued to all soldiers. Few studies, however, describe their actual use in combat casualties. METHODS: A prospective survey of injured who required tourniquets was performed over 7 months in 2006 (NCT00517166 at ClinicalTrials.gov). Follow-up averaged 28 days. The study was at a combat support hospital in Baghdad. Among 2,838 injured and admitted civilian and military casualties with major limb trauma, 232 (8%) had 428 tourniquets applied on 309 injured limbs. We looked at emergency tourniquet use, and casualties were evaluated for shock (weak or absent radial pulse) and prehospital versus emergency department (ED) tourniquet use. We also looked at those casualties indicated for tourniquets but had none used. We assessed survival rates and limb outcome. RESULTS: There were 31 deaths (13%). Tourniquet use when shock was absent was strongly associated with survival (90% vs. 10%; P < 0.001). Prehospital tourniquets were applied in 194 patients of which 22 died (11% mortality), whereas 38 patients had ED application of which 9 died (24% mortality; P = 0.05). The 5 casualties indicated for tourniquets but had none used had a survival rate of 0% versus 87% for those casualties with tourniquets used (P < 0.001). Four patients (1.7%) sustained transient nerve palsy at the level of the tourniquet. No amputations resulted solely from tourniquet use. CONCLUSIONS: Tourniquet use when shock was absent was strongly associated with saved lives, and prehospital use was also strongly associated with lifesaving. No limbs were lost due to tourniquet use. Education and fielding of prehospital tourniquets in the military environment should continue. Comment in
  • FIGURE 3. Increase in survival rate by tourniquet use. By breaking down, the tourniquet use by whether the patient was prehospital or ED, whether there was shock present or absent at the time of application, and whether tourniquets were used or not, a comparison of raw differences in survival rates indicates that the survival benefit to tourniquet use is more strongly related to tourniquet use before the patient has progressed to shock than to prehospital use.
  • Survival With Emergency Tourniquet Use to Stop Bleeding in Major Limb Trauma COL John F. Kragh, Jr., MC, USA,* Thomas J. Walters, PhD,* David G. Baer, PhD,* LTC Charles J. Fox, MC, USA,† Charles E. Wade, PhD,* Jose Salinas, PhD,* and COL John B. Holcomb, MC, USA* Objective: The purpose of this study was to determine if emergency tourniquet use saved lives. Summary Background Data: Tourniquets have been proposed as lifesaving devices in the current war and are now issued to all soldiers. Few studies, however, describe their actual use in combat casualties. Methods: A prospective survey of injured who required tourniquets was performed over 7 months in 2006 (NCT00517166 at ClinicalTrials.gov). Follow-up averaged 28 days. The study was at a combat support hospital in Baghdad. Among 2838 injured and admitted civilian and military casualties with major limb trauma, 232 (8%) had 428 tourniquets applied on 309 injured limbs. We looked at emergency tourniquet use, and casualties were evaluated for shock (weak or absent radial pulse) and prehospital versus emergency department (ED) tourniquet use. We also looked at those casualties indicated for tourniquets but had none used. We assessed survival rates and limb outcome. Results: There were 31 deaths (13%). Tourniquet use when shock was absent was strongly associated with survival (90% vs. 10%; P 0.001). Prehospital tourniquets were applied in 194 patients of which 22 died (11% mortality), whereas 38 patients had ED application of which 9 died (24% mortality; P 0.05). The 5 casualties indicated for tourniquets but had none used had a survival rate of 0% versus 87% for those casualties with tourniquets used ( P 0.001). Four patients (1.7%) sustained transient nerve palsy at the level of the tourniquet. No amputations resulted solely from tourniquet use. Conclusions: Tourniquet use when shock was absent was strongly associated with saved lives, and prehospital use was also strongly associated with lifesaving. No limbs were lost due to tourniquet use. Education and fielding of prehospital tourniquets in the military environment should continue. ( Ann Surg 2009;249: 1–7)
  • J R Army Med Corps.  2007 Dec;153(4):314-6. Intra-osseous access (EZ-IO) for resuscitation: UK military combat experience. Cooper BR ,  Mahoney PF ,  Hodgetts TJ ,  Mellor A . Source 212 Field Hospital RAMC(V). Abstract Military trauma produces predominantly blast and fragmentation injury, commonly resulting in haemorrhagic shock. Injury patterns to limbs are such that the conventional sites for venous cannulation may be unsuitable. The EZ-IO (Vidacare, San Antonio) system is one of a number of novel products designed for intraosseous (IO) access in adults or children. In three months of combat casualty care in Helmand Province, Afghanistan, the UK Defence Medical Services used EZ-IO for emergency vascular access on 26 patients (16 adults; 10 children). 23/26 patients had IO access obtained in the emergency department; 3/26 had pre-hospital IO access within a tactically flying helicopter. A total of 32 needles were inserted, with 97% effective function. IO needles were used to administer fluid (crystalloid, packed red cells and fresh frozen plasma) and drugs (analgesics, cardiac arrest drugs, antibiotics, drugs for both rapid sequence induction and maintenance of anaesthesia). No complication of infection was noted, but pain was observed in responsive patients with the pain of infusion exceeding that of the underlying injuries in 3 cases he experience of the UK Defence Medical Services in Afghanistan has demonstrated that the EZ-IO® system has been a key intervention in the resuscitation and treatment of the critically injured. It has allowed prompt administration of analgesia, sedation, anaesthetic drugs, fluid and blood across a spectrumof age groupswhen conventional intravenous accessis impractical or unsuccessful. Intraosseous access using the EZ-IO® system is a simple technique that can be performed rapidly even in the most challenging pre-hospital environments (a tactically flying military helicopter: personalexperience of the authors) and has rapidly become absorbed into theculture of the UK DMS.The speed of obtaining vascular accesscoupledwith the high success rate makes it a primary access route for drug and/or fluid resuscitation in cardiac arrest (any cause) in adults or children in the hospital or pre-hospital setting
  • Fortunately, a lost art in vascular access is being rediscovered. Intraosseous infusion of medications and fl uids, once limited only to use on children, is now becoming a reliable access site for adults. The technique was widely used by military medics during World War II to save the lives of wounded soldiers, but fell into disuse after the war because at that time there were not yet paramedics in this country. Ambulance attendants did not start IVs in the fi eld; therefore, there was no need for intravascular access or intraosseous (IO) access. However, there is now a renewed interest in IO access for adults when standard IV access is diffi cult or impossible. It has proven to be an invaluable tool for treating seriously ill or injured patients. It is safe, easy, fast and effective. It takes away some of the stress of treating patients in shock by providing a reliable back up for vascular access for nearly every emergency. The 2005 American Heart Association ACLS guidelines recommend adult IO access when IV access is unavailable during cardiac arrest, prior to attempting to administer medications via a central line or an endotracheal (ET) tube. Intraosseous infusion was widely used by military medics during World War II to save the lives of injured soldiers.9 More than 4,000 cases of IO use during the war are documented. The U.S. military considered IO infusion a standard practice in the treatment of seriously wounded soldiers. Prior to the use of IO access, many soldiers hemorrhaged to death because medics could not establish IV access in shock patients. The fi rst documented life saved by IO administration was that of a 19-year-old B-29 crew member who was critically wounded while fl ying over Japan
  • 3.4 Permissive hypotension and minimal volume resuscitation Historically, the management of haemorrhagic shock has emphasised fluid resuscitation with crystalloid solution, to achieve and maintain a normal blood pressure.21, 22 However, aggressive volume resuscitation can cause serious problems, including: • oedema, compartment syndrome23 and acute lung injury • exacerbation of anaemia, thrombocytopenia and coagulopathy due to haemodilution24-26 • exacerbation of bleeding due to possible clot disruption.24, 27 In contrast, permissive hypotension and minimal volume resuscitation are strategies in which systolic blood pressures of 80–100 mm Hg are tolerated while bleeding is controlled.28 These concepts are not new (they date back to World War I 29) and several studies have shown survival benefit.30, 31 Permissive hypotension is widely practised for ruptured abdominal aortic aneurysms.32, 33 Permissive hypotension is contraindicated in patients with traumatic brain injury, because reduced perfusion pressure and oxygenation can lead to secondary brain injury.34
  • Abstract OBJECTIVE: The objective of this study was to determine the optimal use of fresh-frozen plasma (FFP) in trauma. Our hypothesis was that a higher FFP: packed red blood cells (PRBC) ratio is associated with improved survival. METHODS: This is a 6-year retrospective trauma registry and blood bank database study in a level I trauma center. All massively transfused patients (> or =10 PRBC during 24 hours) were analyzed. Patients with severe head trauma (head Abbreviated Injury Severity score > or =3) were excluded from the analysis. Patients were classified into four groups according to the FFP:PRBC ratio received: low ratio (< or =1:8), medium ratio (>1:8 and < or =1:3), high ratio (>1:3 and < or =1:2), and highest ratio (>1:2). RESULTS: Of 25,599 trauma patients, 4,241 (16.6%) received blood transfusion. Massive transfusion occurred in 484 (11.4%) of the transfused. After exclusion of 101 patients with severe head injury 383 patients were available for analysis. The mortality rate decreased significantly with increased FFP transfusion. However, there does not seem to be a survival advantage after a 1:3 FFP:PRBC ratio has been reached. Using the highest ratio group as a reference, the relative risk of death was 0.97 (p = 0.97) for the high ratio group, 1.90 (p < 0.01) for the medium ratio group, and 3.46 (p < 0.01) for the low ratio group. There was an increasing trend toward more FFP use during time with the mean units per patient increasing 83% from 6.3 +/- 4.6 in 2000 to 11.5 +/- 9.7 in 2005. CONCLUSION: Higher FFP:PRBC ratio is an independent predictor of survival in massively transfused patients. Aggressive early use of FFP may improve outcome in massively transfused trauma patients.
  • J Trauma Acute Care Surg. 2012 Aug;73(2):358-64; discussion 364. Debunking the survival bias myth: characterization of mortality during the initial 24 hours for patients requiring massive transfusion. Brown JB, Cohen MJ, Minei JP, Maier RV, West MA, Billiar TR, Peitzman AB, Moore EE, Cushieri J, Sperry JL; Inflammation and Host Response to Injury Investigators. Source Division of General Surgery and Trauma, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA. Abstract BACKGROUND: Controversy surrounds the optimal ratios of blood (packed red blood cell [PRBC]), plasma (fresh frozen plasma [FFP]) and platelet (PLT) use for patients requiring massive transfusion (MT) owing to possible survival bias in previous studies. We sought to characterize mortality during the first 24 hours while controlling for time varying effects of transfusion to minimize survival bias. METHODS: Data were obtained from a multicenter prospective cohort study of adults with blunt injury and hemorrhagic shock. MT was defined as 10 U of PRBC or more over 24 hours. High FFP/PRBC (≥1:1.5) and PLT/PRBC (≥1:9) ratios at 6, 12, and 24 hours were compared with low ratio groups. Cox proportional hazards regression was used to determine the independent association of high versus low ratios with mortality at 6, 12, and 24 hours while controlling for important confounders. Cox proportional hazards regression was repeated with FFP/PRBC and PLT/PRBC ratios analyzed as time-dependent covariates to account for fluctuation over time. Mortality for more than 24 hours was treated as survival. RESULTS: In the MT cohort (n = 604), initial base deficit, lactate, and international normalized ratio were similar across high and low ratio groups. High 6-hour FFP/PRBC and PLT/PRBC ratios were independently associated with a reduction in mortality risk at 6, 12, and 24 hours (hazard ratio [HR] range, 0.20-0.41, p < 0.05). These findings were consistent for 12-hour and 24-hour ratios. When analyzed as time-dependent covariates, a high FFP/PRBC ratio was associated with a 68% (HR, 0.32; 95% confidence interval [CI], 0.12-0.87, p = 0.03) reduction in 24-hour mortality, and a high PLT/PRBC ratio was associated with a 96% (HR, 0.04; 95% CI, 0.01-0.94, p = 0.04) reduction in 24-hour mortality. Subgroup analysis revealed that a high 1:1 ratio (≥1:1.5) had a significant 24-hour survival benefit relative to a high 1:2 (1:1.51-1:2.50) ratio group at both 6 hours (HR, 0.19; 95% CI, 0.03-0.86, p = 0.03) and 24 hours (HR, 0.25; 95% CI, 0.06-0.95, p = 0.04), suggesting a dose-response relationship. A high FFP/PRBC or PLT/PRBC ratio was not associated with development of multiple-organ failure, nosocomial infection, or adult respiratory distress syndrome in a 28-day Cox proportional hazards regression. CONCLUSION: Despite similar degrees of early shock and coagulopathy, high FFP/PRBC and PLT/PRBC ratios are associated with a survival benefit as early as 6 hours and throughout the first 24 hours, even when time-dependent fluctuations of component transfusion are accounted for. This suggests that the observed mortality benefit associated with high component transfusion ratios is unlikely owing to survivor bias and that early attainment of high transfusion ratios may significantly lower the risk of mortality in MT patients.
  • Background: Multiple observational studies have reported that blood product component ratios (i.e., plasma:platelets:RBCs) that approach the 1:1:1 ratio, found in fresh whole blood, are associated with significant decreases in truncal hemorrhagic death and in overall 24-hour and 30-day mortality among injured patients. The rationale for the 1:1:1 ratio is that the closer a transfusion regimen approximates whole blood, the faster hemostasis will be achieved with minimum risk of coagulopathy. The current DoD guideline specifies the use of 1:1:1, and this practice is followed on almost all combat casualties. In other observational studies, leading centers have reported good outcomes across a range of different blood product ratios. For example, a 1:2 plasma:RBC ratio is used with little guidance regarding platelets. The proposed randomized trial is intended to resolve debate and uncertainty regarding optimum blood product ratios. Study Design: Randomized, two-group, controlled Phase III trial with a Vanguard stage. Equal random allocation to treatment using stratified, permuted blocks with randomly chosen block sizes and stratification by site. Objective: To conduct a Phase III multi-site, randomized trial in subjects predicted to have a massive transfusion, comparing the efficacy and safety of 1:1:1 transfusion ratios of plasma and platelets to red blood cells (the closest approximation to reconstituted whole blood) with the 1:1:2 ratio. The co-primary outcomes will be 24-hour and 30-day mortality. The PROPPR Trial will be conducted with exception from informed consent (EFIC). Additionally, laboratory data from the trial will add to the understanding of trauma induced coagulopathy (TIC) and inflammation.
  • The literature review identified 28 studies as being relevant. Of these, six were Level III studies4, 5, 70-73 and the remainder were Level IV.54, 61, 62, 64-66, 74-89 Some studies71, 72 involved a military population and should therefore be interpreted with caution because of baseline differences between military and civilian populations (e.g. higher incidence of severe, penetrating trauma). A survival advantage is associated with decreasing the ratio of RBCs to fresh frozen plasma (FFP), platelets or cryoprecipitate/fibrinogen administered to patients undergoing massive transfusion.65, 76, 78, 89 The decrease in mortality associated with administering low versus high ratios of RBCs to blood components was associated with a significant decrease in deaths from exsanguination. This decrease was attributed to administration of lower ratios of RBCs to FFP, platelets, apheresis platelets and fibrinogen.61, 65, 76, 79 More deaths were reported in patients receiving high ratios of RBCs to blood components compared with low-ratio recipients. However, these results should be interpreted carefully, because of the potential for survival bias (that is, patients who die early are more likely to have received a higher RBC:component ratio).84 The types and content of the studies varied in terms of blood components and the ratios given; therefore, the optimum target ratio is difficult to determine. In trauma patients, a ratio of RBC:FFP:platelets of ≤ 2:1:1 was associated with improved survival.5, 70, 71 A number of these studies used a ratio of, or near to, 1:1.4, 5, 70, 71, 76, 78, 79, 85, 89 Other studies used a ratio of < 2:1:1.5, 70, 71 However, based on analysis of the available studies and the possibility of survival bias, it is not possible to recommend a target ratio of RBC:FFP:platelets. In non-trauma patients, there were insufficient data to support or refute the use of a defined ratio of blood component replacement. Although these patients do not have the initial coagulopathy commonly seen in trauma, critical bleeding may still result in development of hypothermia, acidosis and coagulopathy. Coordination of the management of these patients through use of an MTP is recommended. Blood component replacement should be guided by clinical assessment and results of coagulation tests. Fibrinogen is an essential component of the coagulation system, due to its role in initial platelet aggregation and formation of a stable fibrin clot. Current critical bleeding guidelines recommend keeping the fibrinogen level above 1.0 g/L.14, 90 If fibrinogen levels are not maintained using FFP, replacement using cryoprecipitate or fibrinogen concentrate is indicated. However, in the setting of major obstetric haemorrhage, early administration of cryoprecipitate or fibrinogen concentrate may be necessary. Optimum management requires prompt action, as well as good communication and coordination between treating clinicians, diagnostic laboratories and the transfusion service provider. This is best facilitated by the development and deployment of an MTP that clearly outlines responsibilities and requirements. A template MTP was developed by the CRG (see Section 4.10). Local adaptation of such a protocol – taking into account blood component availability and other resources – fosters a coordinated multidisciplinary approach.
  • Introduction Uncontrolled haemorrhage is the leading cause of death on the battlefield 11,16 and the second leading cause after civilian trauma.51 In modern combat, most injuries are penetrating and affect predominantly the limbs11,16: exsanguination from extremity wounds accounts for over half of all preventable deaths on the battlefield.11 Junctional zones, such as the groin, axilla, neck, and perineum present a particular problem to the medic trying to gain control of a haemorrhaging wound.39 These areas contain large vascular structures and proximal surgical control cannot be achieved within the extremity; they are unsuitable wounds for tourniquet application and it is difficult to maintain effective compression. In a military operational setting, for many reasons, evacuation of seriously injured casualties can be significantly delayed. In civilian mass casualty incidents, or in remote environments, evacuation may also be delayed. Casualty care doctrine cannot therefore rely on achieving rapid surgical control of bleeding and non-surgical strategies must be refined to prevent fatal exsanguinations in the field. With these goals in mind, several enhanced haemostatic dressings have been designed and assessed for their ability to control life-threatening haemorrhage on the battlefield. In 2003, Pusateri cited seven criteria for the ideal prehospital topical haemostatic dressing.46 The ability to stop haemorrhage from actively bleeding large arteries and veins within 2 min, delivered through a pool of blood; ready to use requiring no on scene mixing or preparation; simple to apply by casualty, non-medical first responder or medical staff; lightweight and durable; minimum 2 year shelf-life and wide temperature storage capability (ideally 10–55 8C); risk free – no injury or viral disease transmission risk; and inexpensive. While the ideal dressing has yet to be discovered, advanced dressings have already been deployed on military operations and by civilian emergency services. This paper reviews the current literature regarding topical prehospital haemostatic dressings and compares their ability to achieve and maintain haemostasis after life-threatening haemorrhagic injury. There have been thorough reviews of topical surgical haemostatics, but none that focus on pre-hospital use; instead they examine intraoperative haemostatic solutions and give prehospital dressings a cursory mention.
  • These products are agents applied to hemorrhaging vessels to facilitate activation of the coagulation cascade and are designed to be applied to extremities early in the treatment process. The intended utilization is to control hemorrhage in junctional anatomic regions. These are areas that are located in anatomical bridges, such as the axilla and high groin, and are areas often not amenable to proper placement of tourniquets, to staunch life-threatening hemorrhage. This is commonly known as “non-compressible” hemorrhage. Personnel having to deal with massive hemorrhage from junctional wounds are left with prolonged manual pressure as the only means of assistance. Due to the kinetics of the battlefield, with changing geography and enemy fire, the need to move the patient repeatedly during evacuation, as well as the general difficulty in applying adequate pressure in these regions, such application of pressure is neither practical nor efficacious. This has led to the development of topical substances that can accelerate coagulation for wounds that are not adequately controlled with tourniquets. The earlier version was a granule based product with zeolite as the active component. This product worked by evacuating the fluid content of the hemorrhaging vessel, promoting coagulation, as well as activating several steps in the clotting cascade. One drawback to this agent was that a tremendous amount of heat was generated. This heat production was subsequently implicated in cutaneous burns in patients. Additionally, while very effective if utilized properly, it often required more technical capabilities to clear the wound, temporarily dry it, and rapidly place the granules than were readily available in a far-forward, point of injury location. A more recently developed topical hemostatic utilizes a variant of rolled gauze impregnated with kaolin, which rapidly activates the coagulation cascade. The application is simple, as most medical and non-medical personnel are capable of packing a wound with gauze.5 Continued testing and development of topical agents is a priority for military medicine.
  • While the ideal dressing has yet to be discovered, advanced dressings have already been deployed on military operations and by civilian emergency services
  • Kaolin-based QuikClot gauze has been subjected to safety and efficacy studies that were performed by the US Army Institute of Surgical Research (USAISR) and the Naval Medical Research Center.  Arterial incisions were made in the USAISR study and the wounds were treated with kaolin-based QuikClot gauze, placebo QuikClot gauze (without kaolin), HemCon gauze, Celox-D, and TraumaStat. 6  Kaolin-based QuikClot gauze was found to be the most effective product among the dressings tested in the USAISR study allowing the least amount of hemorrhage and resulted in the highest survival rate in the animals tested. 6 The Tactical Combat Casualty Care (TCCC) committee has revised the TCCC guidelines to state the Combat Gauze (the kaolin-based QuikClot product) is the first line of treatment for life-threatening hemorrhage on external wounds that are not amendable to tourniquet placement.  The decision to update the TCCC guideline concerning Combat Gauze was based on the test results from the USAISR study. 6 The hemostasis time for kaolin-based QuikClot gauze was typically five minutes according to a clinical study that was performed on 40 consecutive patients that had been subjected to femoral diagnostic or interventional procedures. 7 In conculusion, kaolin-based QuikClot gauze products are manufactured with safe and proven materials for use as hemostatic agents in the temporary control of traumatic bleeding.  The Department of Defense and the National Institute of Health are funding research to explore other applications of QuikClot in the healthcare markets because QuikClot has been accepted by all branches of the US military.  
  • Kaolin is an inert mineral and it promotes clotting by two main modes of action: Kaolin promotes the activation of Factor XII (FXII) in the presence of kallikrein and high molecular weight kininogen. 3  Activated FXII initiates the intrinsic clotting pathway via the activation of Factor XI. 3  Activated FXI continues the coagulation pathway that ends with the formation of a fibrin clot. 2 Kaolin promotes the activation of platelet-associated FXI 4  and it is a distinct and separate molecule from plasma FXI. 5  Activated platelet-associated FXI initiates the intrinsic clotting pathway in normal and FXII deficient patients. 4 Kaolin-based QuikClot gauze has been subjected to safety and efficacy studies that were performed by the US Army Institute of Surgical Research (USAISR) and the Naval Medical Research Center.  Arterial incisions were made in the USAISR study and the wounds were treated with kaolin-based QuikClot gauze, placebo QuikClot gauze (without kaolin), HemCon gauze, Celox-D, and TraumaStat. 6  Kaolin-based QuikClot gauze was found to be the most effective product among the dressings tested in the USAISR study allowing the least amount of hemorrhage and resulted in the highest survival rate in the animals tested. 6 The Tactical Combat Casualty Care (TCCC) committee has revised the TCCC guidelines to state the Combat Gauze (the kaolin-based QuikClot product) is the first line of treatment for life-threatening hemorrhage on external wounds that are not amendable to tourniquet placement.  The decision to update the TCCC guideline concerning Combat Gauze was based on the test results from the USAISR study. 6 The hemostasis time for kaolin-based QuikClot gauze was typically five minutes according to a clinical study that was performed on 40 consecutive patients that had been subjected to femoral diagnostic or interventional procedures. 7
  • Mineral Zeolite (QuikClot) Mineral zeolite hemostatic agents such as QuikClot are granular powders consisting of molecular sieves made of inert minerals like oxides of silicon, aluminum, magnesium, and sodium. QuikClot absorbs liquid at the site of a wound thereby increasing the local concentration of clotting factors, platelets, and erythrocytes to stimulate hemostasis (Table 1).92 It is stable, easy to use, and costs only $10 per packet. It was issued to US forces in Iraq and Afghanistan as a hemostatic agent. QuikClot is very effective for low-pressure bleeding, but less effective for high-pressure bleeding. A study of 103 documented military and civilian cases indicates that QuikClot controlled hemorrhage in 92% of those applications. QuikClot had 100% efficacy when used by first responders in the field; the only failures occurred when QuikClot was used by physicians as a last resort in coagulopathic moribund patients.101 However, other anecdotal evidence from Iraq describes how high-pressure bleeding can force QuikClot powder out of the wound to render it useless.88 Although QuikClot is only approved for controlling external hemorrhage, 20 of the cases in the above study were instances of intracorporeal use by trauma surgeons. In one case of intracorporeal usage, a major complication arose from scar tissue formation due to a foreign body reaction. In swine with complex groin injury and delayed hypotensive resuscitation, all subjects treated with QuikClot survived, while only half of those treated with standard gauze compression survived.92 The success of QuikClot in those experiments is probably dependent on blood pooling in the swine inguinal cavity- which was very likely due to hypotensive slow blood flow.88 In contrast, human artery transections would have higher flow and no pooling, thus making clotting more difficult, an explanation that agrees with the anecdotal accounts of QuikClot failure under high-pressure bleeding in Iraq. In an experiment on swine with complex groin injuries, 11 of 12 swine survived; the sole death was due to the powder not covering the incised vessels but migrating into an adjacent soft tissue void. However, following statistical analysis the authors deemed that survival rate was insignificant when compared with the 6 of 12 that survived with the standard dressing. Decrease of QuikClot in effectiveness for high-pressure bleeding has been addressed by the manufacturer in its latestgeneration product. The mineral zeolite is now enclosed in a gauze mesh pouch, so that it can be applied at the wound site under pressure without the zeolite being washed away by blood flow. In unpublished studies in Yorkshire swine at our institution at Duke University Medical Center, the enclosure of the zeolite appeared to effectively surmount that difficulty. The absorption of liquid by mineral zeolite is an exothermic process; in the initial formulation of QuikClot (used in the studies cited above), the heat released could result in tissue damage. Wound temperatures measured in animal studies had range from 42°C92 to 70.8°C depending on the blood flow and amount of QuikClot added. Of the 103 documented uses of QuikClot, 25% of the patients had reported concomitant mild to severe pain and discomfort, with 3 cases of burns.101 The manufacturer addressed this problem by prehydrating the zeolite so that it absorbs water less exothermically. In our own experience, we measured the maximum temperature of QuikClot used to treat groin injuries in Yorkshire swine to be 42.3°C, confirming the manufacturer’s claim addressing this shortcoming. The latest generation product appears to address the problems posed by the initial formulation of QuikClot: embedding the zeolite in surgical mesh so it can be used as a compress, and prehydrating the zeolite so that it absorbs water less exothermically. According to unpublished results at Duke University Medical Center the manufacturer’s claims appear valid. The product is now marketed to the general public for use in first-aid kits. However to date, there has not been any published independent studies of the modified product’s effectiveness; all of the studies cited above refer to the original product prior to modification.
  • Objectives   To characterize contemporary use of tranexamic acid (TXA) in combat injury and to assess the effect of its  administration  on total blood product use, thromboembolic complications, and mortality. Design   Retrospective observational study comparing TXA administration with no TXA in patients receiving at least 1 unit of packed red blood cells. A subgroup of patients receiving massive transfusion (≥10 units of packed red blood cells) was also examined. Univariate and multivariate regression analyses were used to identify parameters associated with survival. Kaplan-Meier life tables were used to report survival. Setting   A Role 3 Echelon surgical hospital in southern Afghanistan. Patients   A total of 896 consecutive admissions with combat injury, of which 293 received TXA, were identified from prospectively collected UK and US trauma registries. Main Outcome Measures   Mortality at 24 hours, 48 hours, and 30 days as well as the influence of TXA administration on postoperative coagulopathy and the rate of thromboembolic complications. Results   The TXA group had lower unadjusted mortality than the no-TXA group (17.4% vs 23.9%, respectively;  P  = .03) despite being more severely injured (mean [SD] Injury Severity Score, 25.2 [16.6] vs 22.5 [18.5], respectively;  P  < .001). This benefit was greatest in the group of patients who received massive transfusion (14.4% vs 28.1%, respectively;  P  = .004), where TXA was also independently associated with survival (odds ratio = 7.228; 95% CI, 3.016-17.322) and less coagulopathy ( P  = .003). Conclusions   The use of TXA with blood component–based resuscitation following combat injury results in improved measures of coagulopathy and survival, a benefit that is most prominent in patients requiring massive transfusion. Treatment with TXA should be implemented into clinical practice  as part of a resuscitation strategy following severe wartime injury and hemorrhage.
  • ABERDEEN PROVING GROUND, Md. (Sept. 19, 2012) -- The U.S. Army explored whether real-time, electronic point-of-treatment care was possible or practical this summer at its integrated capabilities testbed at Fort Dix, N.J. Key medical and technical personnel from the U.S. Army Medical Research & Materiel Command and the U.S. Army Research, Development and Engineering Command combined prototype medical military software with commercial hand-held technologies and tactical 4G networks to send medical information from the point of injury on the battlefield back to the doctor for real-time communication and decision making. "It's going to build confidence in the medic on the field that's isolated with a severely wounded Soldier," said Carl Manemeit, Physiological Monitoring project lead for the MRMC's Telemedicine & Advanced Technology Research Center, or TATRC.  "If you've ever seen the movie, 'Black Hawk Down,' the medic is trying to treat the guy with the artery issue in his leg; the medic goes through all his resources, and once he exhausted all his knowledge, he was stuck," Manemeit said. If he had been connected to the surgeons back at the treatment facility, they could have given him more guidance on how to save that Soldier's life. By injecting this expertise, we might be able to do that one thing that could save some guy's life; that's what we're looking to do." Medics utilized man-portable physiological monitoring devices with streaming video, voice and photo capability, and sent electronic Tactical Casualty Care Cards, or TC3, over a tactical network to the surgical facility so surgeons could see injuries and what treatment had been performed prior to the patient's arrival. "There's an information gap that lies between the point of injury on the field and point of treatment back at a medical facility," said Dr. Gary R. Gilbert, TATRC Research, Development, Test and Evaluation program manager for Secure Telemedicine. "We need to do a better job of being able to record what the medic saw and did prior to the patient being evacuated to the treatment facility, and we want this record to be transmitted to the Soldier's permanent health records." "Now when the patient goes to a combat support hospital, or gets back to Walter Reed for further care, the doctors can see what happened in the field; and five years from now when the patient goes into a VA hospital seeking treatment, the care providers can see everything that's been done," Gilbert said. Currently, medics fill out a paper TC3 that's attached to the injured Soldier before evacuation to the battalion aid station or the combat support hospital. In some cases, the TC3 never makes it back to the treatment facility, and the information never makes it to the patient records.  "One of the issues I had with the card is that it's a piece of paper held on with a metal wire," said Spc. Daniel Vita, U.S. Army Medical Research Institute for Infectious Diseases, Fort Detrick, Md. "Pretty much, you would have attached it to the patient through his zipper or around his wrist, but you potentially had the problem of ripping the paper from the metal loop." Vita, who was a medic with the 130th Engineer Brigade Headquarters in Iraq, preferred using tape and a sharpie because "it stayed." "I like the idea of an electronic TC3 because it's simpler," Vita said. "It's a lot easier for the information to get to where it needs to go and it makes it legible. When you filled out a TC3 card and put it on the patient, they didn't know what was happening until that patient and card got to them. Now doing it electronically, you can send it ahead to the level two or three so they have an idea of what kinds of patients and casualties are coming in." The combination of secure tactical communications and knowledge management may also help brigade surgeons prioritize treatment and evacuation assets so the most critically injured can be treated first. "The Army uses medevac, but the bad news is that it costs about $20,000 per patient flight," said Dave Williams, Project Manager for Theater Tele-Health Initiatives, TATRC. "And if you have six assets and 12 patients, who should they get first? If we can determine which patients can be held and which can be treated and stabilized on site, it might be a less expensive way to save a patient's life." The work was performed at the integrated capabilities testbed operated by Product Director Command, Control, Communications, Computers, Intelligence, Surveillance, Reconnaissance and Network Modernization, an R&D program within U.S. Army RDECOM's communications-electronics RD&E center, CERDEC. "This is a forgiving environment because it's designed for testing and solution proving," Gilbert said. "If things don't work, that's OK; you find out what doesn't work and you fix it here. There are a lot of technologies required to make this work, and we don't have all of these. CERDEC is helping to fill in those gaps by providing a variety of radio capabilities that you wouldn't get at a real brigade: SRW, WNW, ANW2, deployable 4G, Airborne relay, connection to Army WIN-T. They provide the infrastructure, and we just bring the application." PD C4ISR & Network Modernization focuses on the future network, near-term and several years out, providing the Army with a relevant venue to assess next-generation technologies and to facilitate technology maturation. The program is also a key component in CERDEC's support of the agile acquisition process, utilizing its field lab environment to perform risk mitigation and candidate assessment/selection for future Network Integration Rehearsal/Exercise events.  "These guys are not only preparing the current force to be successful, they're closing the gaps for the future force with each iteration of these integrated capabilities events," Williams said. "You don't solve all the problems in one 12-month cycle. This venue is providing the medics an opportunity to get inside the Program Objective Memorandum cycle to come up with those solutions and iteratively solve them as technologies emerge and grow with us. This has been a complete team effort to develop a solution that did not exist six years ago." This is the third year that PD C4ISR & Network Modernization has examined network capabilities that could support the medic/first responder's mission. During 2011, PD C4ISR & Network Modernization combined fielded tactical radios such as the Enhanced Position Location Reporting System with the Soldier Radio Waveform to see if it was possible and feasible to provide enhanced bandwidth and over-the-horizon communications for hand-held medical data. This year, a 4G cellular mesh network was implemented, using SRW to bridge back to the tactical network.  "We're examining how best to combine the future and current so we can enable the medical community to perform their mission more efficiently," said Jason Sypniewski, chief for PD C4ISR & Network Modernization's Integrated Event Design & Analysis branch. "We're looking at the Soldier Radio Waveform because it's a self-healing waveform that allows non-line-of-sight communication; that's the vision for where the Army wants to go. We've looked at EPLRS because it's an existing asset on which the medical community might could recapitalize." "Cellular technology could be the future of tele-health on the modern battlefield, but we need to know if it can be done, and if so, would it actually enhance the delivery of information?" Sypniewski said. "As decision makers look at network modernization, this is the type of information they will want in order to help them make informed decisions regarding telemedicine capabilities and the networks on which they're going to ride. Our mission is to provide this."
  • TELEMEDICINE Although the wide use of telemedicine in Iraq and Afghanistan has been hindered by a lack of satellite bandwidth, this technology has been utilized in combat support hospitals to successfully diagnose dermatological conditions such as leishmaniasis and various ocular and dental conditions. This limited use was mainly due to the timing of technological developments. Although the idea was being implemented, the necessary infrastructure for a secured system was not ready. However, medical personnel have used email to send pictures of casualties, wounds, and medical records to personnel who were preparing to receive the casualties, as well as to those who were monitoring these casualties in the United States. Medics have also used text messages to communicate with medical personnel about injured soldiers. Teleradiology has allowed the electronic transfer of CT and other radiological images to Landstuhl Regional Medical Center. Recently, a high-tech telesurgical mentoring system was installed in Mosul by the Army’s Telemedicine and Advanced Technology Center (TATRC). Although this unit was not widely utilized owing to the decrease in casualties, it was equipped with new capabilities to greatly facilitate consultations, such as laser pointers in the surgical lights to help remote surgeons clearly identify areas of focus in surgical fields. On subsequent missions, this telesurgical system, which delivers surgical capabilities closer to the battlefield, is expected to provide improved far-forward care and management of casualties. The main advantage of telemedicine in the immediate future will likely be its usefulness for recording care. When logistical issues are solved, telemedicine could become a useful adjunct, particularly in deployment areas of rugged terrain or widely dispersed troops. In such environments, telemedicine will not only foster consultation and collaboration but may lso enhance the safety of medical personnel by reducing the need to travel to tend to wounded troops. Although the evolution of telemedicine will improve our ability to care for casualties, there is no replacement for well-trained personnel.
  • Holley: WAR - What is it good for?

    1. 1. War – What is it Good For?Anthony HolleyIntensivistRoyal Brisbane and Women’s Hospital
    2. 2. Declarations No image depicts a wounded Australian. All images previously published/approved. Opinions expressed are not those of the ADF No conflict/financial advantage.
    3. 3. War – What is it Good For?
    4. 4. Probably Nothing!“A great war leaves the country with three armies - an army of cripples, anarmy of mourners, and an army of thieves” German proverb“He who would become a surgeon should join the army and follow it.”Hippocrates
    5. 5. Moving Beyond Case Reports High volumes of trauma Extensive trauma Unique injuries Significant distances to “standard facilities”
    6. 6. Triage Napoleonic wars Baron Larrey (1766-1842) Established anambulance service and asystem of triage
    7. 7. “The field army has an opportunity for research thatcannot be duplicated by any other organization ...No other institution has an opportunity orresponsibility in the field of trauma comparable tothat of the Army Medical Service”.Battle Casualties in Korea, Studies of the SurgicalResearch Team, 1955, p. 16.
    8. 8. One month after the invasion of Iraq in2003…. US Army Surgeon General sent a team intoIraq on a fact-finding mission. “Ide ntify what was wro ng and fix it. ”
    9. 9. Perkins et al. Research and Analytics in Combat Trauma Care. Converting Dataand Experience to Practical Guidelines. Surg Clin N Am 92 (2012) 1041–1054
    10. 10. Deployed Combat CasualtyResearch Team Physician director Deputy director nurse 3 research nurses A senior noncommissioned officer.
    11. 11. Aims1. Improve organization anddelivery of trauma care.2. Develop clinical practiceguidelines.3. Ensure continuity throughchain of evacuation.4. Conferences.5. Evaluate new equipment.6. Populate trauma registry.7. Facilitate formal research.Joint Theater Trauma System (JTTS)and Joint Theater Trauma Registry (JTTR)
    12. 12. Clinical Practice GuidelinesReviewed1 Acoustic Trauma and Hearing Loss February 16, 20102 Amputation February 16, 20103 Blunt Abdominal Trauma June 30, 20094 Burn Care December20, 20095 Catastrophic Care February 16, 20106 Cervical Spine Evaluation June 30, 20107 Compartment Syndrome (CS) and the Role of Fasciotomy in Extremity WarWounds April 30, 20098 Damage Control Resuscitation at Level IIb/III Treatment Facilities February 13, 20099 Emergent Resuscitative Thoracotomy May 6, 200910 Fresh Whole Blood (FWB) Transfusion January 12, 200911 Frozen and Deglycerolized Red Blood Cells (RBCs) June 30, 201012 Hypothermia Prevention, Monitoring, and Management June 30, 201013 Infection Control February 16, 201014 Inhalation Injury and Toxic Industrial Chemical Exposure November7, 200815 Initial Care of Ocularand Adnexal Injuries February 16, 201016 IntratheaterTransferand Transport of Level IIand IIICritical Care Trauma Patients November19, 200817 Management of Patients with Severe Head Trauma November23, 201018 Management of Patients with Severe Head Trauma June 30, 201019 Management of WarWounds February 16, 201020 Nutrition February 16, 201021 Pelvic Fracture Care June 30, 201022 Post-Splenectomy Vaccination June 30, 201023 Prevention of Deep Venous Thrombosis (DVT) November21, 200824 Spine Injury Surgical Management and Transport July 9, 201025 Trauma Airway Management June 30, 201026 Urologic Trauma Management June 30, 201027 Use of Electronic Clinical Documentation in the CENTCOMAOR June 30, 201028 Use of Trauma Flow Sheets December1, 200829 VentilatorAssociated Pneumonia - February 16, 201030 VascularInjury November7, 2008Source: http://www.usaisr.amedd.army.mil/cpgs.html
    13. 13. Does the Military Experience contributeto Civilian Medicine? Age Co-morbidities Injury mechanism Environment Limitations Expectations Levels of evidence
    14. 14. EXTREMITY INJURIES1Johnson, Burns et al. 2007; 2Gustilo and Anderson2002Injury Severity Relative to Civilian Medicine - Fractures
    15. 15. Civilian Medicine? New concepts in medical care introduced during warare often integrated into civilian practice. Require validation through quality prospectiveresearch.
    16. 16. So What Have We Learnt Over theLast Decade?
    17. 17. Casualties of War — Military Care for the Wounded from Iraq and AfghanistanAtul Gawande, M.D., M.P.H. N Engl J Med 2004; 351:2471-2475
    18. 18. Potentially PreventableDeaths in Iraq and AfghanistanCNS 9% Other 4%Airway 14%Hemorrhage85%31% Compressible (prehospital target)69% Non-Compressible (FST/CSH target)(Kelly J., J Trauma 64:S21, 2008)n= 232
    19. 19. The Fundamentals of Casualty CareUnchanged Overthe Past 100 Years:1. Pre-hospital/point ofwounding care2. Safe evacuation fromfront-line combat3. Rapid control ofhaemorrhage4. Prevention ofcontamination/infectious sources.
    20. 20. Why Are We Doing Better? Improved PersonalProtectiveEquipment Tactical CombatCasualty Care Fasterevacuationtimes BettertrainedmedicsHolcomb et al J Trauma 2006
    21. 21. Improved Personal ProtectiveEquipment
    22. 22. Tactical Combat Casualty Care25 >75% of all combat deaths occur before thecasualty reaches a Medical TreatmentFacility The fate of the injured often lies in thehands of the one who provides the first careto the casualty.
    23. 23. Previous Approach to Combat MedicTraining26 Historically modeled on civilian courses EMT, PHTLS, BTLS, ATLS Trained to standard of care in civilian settings No consideration for tactical elements
    24. 24. Phases of Care in TCCC Care Under Fire Tactical Field Care Tactical Evacuation Care
    25. 25. Pre-Hospital / Point of InjuryCare - MARCH Massivehaemorrhage control Airway Respiration Circulation Hypothermia
    26. 26. Early analysis of autopsy reportsfrom Afghanistan and Iraq: Emphasized preventable deaths due toexsanguination from extremity trauma. Key focus of intervention.
    27. 27. Tourniquets in WWII“We believe that thestrap-and-buckletourniquet incommon use isineffective in mostinstances underfield conditions…itrarely controlsbleeding no matterhow tightly applied.”
    28. 28. Annals of Surgery • Volume 245, Number 6, June 2007
    29. 29. Tourniquets Recent reviews oftourniquet use incombat Low complicationrates Positive survivalbenefit
    30. 30. Tourniquets 31stCSH in 2004 165 casualties with severeextremity trauma 67 with prehospitaltourniquets; 98 without Seven deaths Four of the seven deathswere potentially preventablehad an adequate prehospitaltourniquet been placedBeekley et al Journal of Trauma 2008
    31. 31. Data from 2 studies of patients presenting to acombat hospital in Iraq with tourniquets
    32. 32. Tourniquets
    33. 33. TourniquetsTourniquet vs notourniquetShock vs no shockPrehospital vs ED
    34. 34. Tourniquets
    35. 35.  Penetrating injury Police officers Terrorist attacks Wilderness accidents Industrial accidentsTourniquets
    36. 36. Recommendation“In rare situations tourniquet application will benecessary and lifesaving in the civilian pre-hospital setting. Tourniquets are no longeronly considered as a ‘‘last resort’’ device.Practitioners should familiarise themselveswith this simple piece of equipment and beprepared to use it in appropriate cases withoutan irrational fear of complications”.
    37. 37. Intra-osseous access Research and casestudies in the 1940sdemonstrated theusefulness of theintraosseous route forblood, fluids, andmedications. An intraosseous devicesused during World War II.Dublick MA, Holcomb JB. A review of intraosseous vascular access: current statusand military application. Mil Med. 2000; 165:552-559
    38. 38.  Use of intraosseousdevices in trauma istaught andadvocated in theATLS/EMST.Intra-osseous access
    39. 39. Damage Control Resuscitation“Damage Control Resuscitationrepresents the most important advancein trauma care for hospitalized civilianand military casualties from this war.”Cordts, Brosch and Holcomb, J Trauma, 2008
    40. 40. Damage Control Resuscitation Permissive hypotension Fluids Blood products/ratios Warming Abbreviated initial surgery
    41. 41. Permissive hypotension and minimalvolume resuscitationCannon W, Fraser J and Cowell E (1918). The preventive treatment ofwound shock. Journal of the American Medical Association 70:618–621.
    42. 42. Management of critical bleeding should focuson:1. Early recognition of blood loss2. Rapid control of the source of bleeding3. Restoration of circulating blood volume.
    43. 43. Damage Control Resuscitation Acidosis- Base Deficit > - 6 Coagulopathy – INR > 1.5 Hypotension – Systolic B/P < 90 Haemoglobin - < 11 Temperature - < 36 oC Pattern recognition Weak or absent radial pulse Abnormal mental status Severe Traumatic Injury
    44. 44. So what product ratios shouldwe be using to optimiseResuscitation of HaemorrhagicShock?
    45. 45. RatiosProduct ratios
    46. 46. Holcomb JB, Wade CE, Michalek JE, Chisholm GB, Zarzabal LA, Schreiber MA, Gonzalez EA, Pomper GJ,Perkins JG, Spinella PC, Williams KL, Park MS. Increased plasma and platelet to red blood cell ratios improvesoutcome in 466 massively transfused civilian trauma patients. Ann Surg 2008; 248:447-458.
    47. 47. Product ratios Massive data base ~ 25 000 16% transfused 11.4% received massive transfusions 383 patients Logistic regression identified the ratio of FFP to PRBC use asan independent predictor of survival. Higher the ratio of FFP:PRBC the greater the probability ofsurvival. The optimal ratio in this analysis was an FFP:PRBC ratio of1:3 or less.Teixeira PG, Inaba K, Shulman I, Salim A, Demetriades D, Brown C, Browder T, Green D, Rhee P.Impact of plasma transfusion in massively transfusedtrauma patients. J Trauma 2009; 66:693-697.
    48. 48. Hemostatic resuscitation with plasma and platelets in trauma Pär I Johansson, Roberto S Oliveri, Sisse R OstrowskiSection for Transfusion Medicine, Capital Region Blood Bank, Department of Clinical Immunology, Rigshospitalet, University ofCopenhagen, Denmark
    49. 49. Pragmatic, Randomized, Optimal Plateletand Plasma Ratios (PROPPR)University of Washington Phase III trial toevaluate the difference in 24-hour and 30-daymortality among subjects predicted to receivemassive transfusion.
    50. 50. PROPPR Estimated Enrollment: n = 580 Study Start Date: August 2012 Estimated Study Completion Date: August 2015Primary Outcome Measures: 24-hour mortality 30-day mortality Coagulation and inflammatory phenotypes at emergency department admission and over time.Secondary Outcome Measures: Hospital fee Ventilator free and ICU free days Time to haemostasis, major surgical procedures, incidence of transfusion related serious adverseevents. Functional status at time of hospital discharge, initial hospital discharge status
    51. 51. Practice PointIn patients with critical bleeding requiringmassive transfusion, suggested doses ofblood components are:1. FFP: 15 mL/kg2. platelets: 1 adult therapeutic dose3. cryoprecipitate: 3–4 g.
    52. 52. Practice PointIn patients with critical bleeding requiringmassive transfusion, insufficient evidence wasidentified to support or refute the use ofspecific ratios of RBCs to blood components.
    53. 53. Ratios
    54. 54. Provision of ProductsMJA 2010; 192: 203–205Frozen blood products: clinically effective and potentially ideal for remote AustraliaHolley et al.. Anaesth Intensive care. 2013 Jan;41(1):10-9.
    55. 55. Cryopreserved Platelets (-80Cryopreserved Platelets (-80ooC)C)
    56. 56. Cryopreserved vs. Liquid Platelets(CLIP)Cryopreserved vs. Liquid PlateletsApilo t rando m ise d, co ntro lle d, blinde d clinicaltrialo fcryo pre se rve d plate le ts vs. co nve ntio nalliq uid-sto re dplate le ts fo r the m anag e m e nt o f po st-surg icalble e ding• 90 cardiac surgical patients in 3 hospitals (TPCH, RPAH, Austin)• Supported by ANZCA ($94K) and ARCBS ($50K) grants• Will facilitate NH&MRC project grant application in 2014.
    57. 57. Adjuncts to Haemostasis Factor VIIa Topicalhaemostatics Tranexamic acid Prothrombincomplexconcentrates
    58. 58. Topical Haemostatics
    59. 59. Topical Haemostatics Topical Accelerate coagulation Junctional sites non compressible sites
    60. 60. In 2003, Pusateri cited criteria for the idealprehospital topical haemostatic dressing1. Ability to stop haemorrhage from actively bleedinglarge arteries and veins within 2 min.2. Delivered through a pool of blood.3. Ready to use requiring no on scene mixing orpreparation4. Simple to apply by casualty, non-medical firstresponder or medical staff.5. Lightweight and durable.6. Minimum 2 year shelf-life and wide temperaturestorage capability (ideally 10–55 8C).7. Risk free – no injury or viral disease transmissionrisk8. Inexpensive.
    61. 61. Haemostatic Dressings Factor concentrators e.g Zeolite “Quickclot”. Mucoadhesive agents e.g. Hemocon (Chitinbased). Procoagulant supplementors e.g. KaolinQuickclot combat gauze.
    62. 62. Kaolin (inert mineral) Promotes clotting by two main modes ofaction:1. Activation of Factor XII (FXII) in the presenceof kallikrein and high molecular weightkininogen. Activated FXII initiates the intrinsicclotting pathway via the activation of FactorXI. 2. Activation of platelet-associated FXI (a distinctand separate molecule from plasma FXI). 
    63. 63. Haemostatic Dressings
    64. 64. 70CRASH-2trialcollaborators. TheLancet. 2010;376:23-32Effects of tranexamic acid on death,vascular occlusive events, and bloodtransfusion in trauma patients withsignificant haemorrhage (CRASH-2): arandomised, placebo-controlled trialTranexamic acid
    65. 65. Tranexamic AcidTranexamic Acid
    66. 66. Tranexamic AcidTranexamic Acid
    67. 67. Arch Surg. 2012;147(2):113-119. 2011Study profile illustrating the overall cohort and study groups.MATTERs
    68. 68. Arch Surg. 2012;147(2):113-119.2011MATTERs
    69. 69. From: Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) StudyArch Surg. 2012;147(2):113-119.Percentage of patients with hypocoagulopathy on admission to the emergency department (ED) and then the intensive care unit(ICU) following the initial operation. Coagulation data were available for 462 patients in the overall cohort and 155 patients in thegroups that received massive transfusion. TXA indicates tranexamic acid. * P < .05.MATTERs
    70. 70. Arch Surg. 2012;147(2):113-119.Kaplan-Meier survival curve of the overall cohort, including patients receiving tranexamic acid (TXA) vs no TXA. P = .006, Mantel-Cox log-rank test.MATTERs
    71. 71. From: Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) StudyArch Surg. 2012;147(2):113-119.Kaplan-Meier survival curve of the massive transfusion group receiving tranexamic acid (TXA) or no TXA. P = .004, Mantel-Coxlog-rank test.MATTERs
    72. 72. Telemedicine Wide use oftelemedicine in Iraq andAfghanistan hindered bya lack of satellitebandwidth. Remote specialists > 40000 consultsLam DM, Poropatich RK Telemedicine deployments within NATO militaryforces: a data analysis of current and projected capabilities. Telemed J EHealth. 2008 Nov;14(9):946-51
    73. 73. Telemedicine Requires securedsystem. Email to send Images. Electronic transfer ofCT and otherradiological images toLandstuhl RegionalMedical Centre.
    74. 74. War– What is it Good For? Numbers Ideas Need Caution required indirect extrapolationto civilian practice Sadly, at timescivilian practice allto similar to war
    75. 75. Questions?