Hemorrhage remains the primary cause of preventable death on the battlefield and in civilian trauma. Hemorrhage control is multifactorial and starts with point-of-injury care. Surgical hemorrhage ...control and time from injury to surgery is paramount; however, interventions in the prehospital environment and perioperative period affect outcomes. The purpose of this review is to understand concepts and strategies for successful management of the bleeding military patient. Understanding the life-threatening nature of coagulopathy of trauma and implementing strategies aimed at full spectrum hemorrhage management from point of injury to postoperative care will result in improved outcomes in patients with life-threatening bleeding.
Timely and appropriate therapies impact survival. Blood product resuscitation for life-threatening hemorrhage should either be with whole blood or a component therapy strategy that recapitulates the functionality of whole blood. The US military has transfused over 10 000 units of whole blood since the beginning of the wars in Iraq and Afghanistan. The well recognized therapeutic benefits of whole blood have pushed this therapy far forward into prehospital care in both US and international military forces. Multiple hemostatic adjuncts are available that are likely beneficial to the bleeding military patient; and other products and techniques are under active investigation.
Lessons learned in the treatment of combat casualties will likely continue to have positive impact and influence and the management of hemorrhage in the civilian trauma setting.
BACKGROUND
Hemorrhage is the leading cause of preventable death in military and civilian traumatic injury. Blood product resuscitation improves survival. Low‐titer Type O Whole Blood (LTOWB) was ...recently re‐introduced to the combat theater as a universal resuscitation product for hemorrhagic shock. This study assessed the utilization patterns of LTOWB compared to warm fresh whole blood (WFWB) and blood component therapy (CT) in US Military Operations in Iraq/Syria and Afghanistan known as Operation Inherent Resolve (OIR) and Operation Freedom's Sentinel (OFS) respectively. We hypothesized LTOWB utilization would increase over time given its advantages.
STUDY DESIGN AND METHODS
Using the Theater Medical Data Store, patients receiving blood products between January 2016 and December 2017 were identified. Product utilization ratios (PUR) for LTOWB, WFWB, and CT were compared across Area of Operations (AORs), medical treatment facilities (Role 2 vs. Role 3), and time. PUR was defined as number of blood products transfused/(number of blood products transfused + number of blood products wasted).
RESULTS
The overall PUR for all blood products was 17.4%; the LTOWB PUR was 14.3%. Over the study period, the total number of blood products transfused increased 133%. Although the total whole blood (WB) increased from 2.1% to 6.6% of all products transfused, WFWB use remained at 2% while LTOWB transfusions increased from 0.5% to 4%. Transfusion of LTOWB occurred more in austere Role 2 facilities compared to Role 3 hospitals.
CONCLUSIONS
LTOWB transfusion is feasible in austere, far‐forward environments. Further investigation is needed regarding the safety, clinical outcomes, and drivers of LTOWB transfusions.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
Intravenous (IV) resuscitation of burn patients has greatly improved outcomes and become a cornerstone of modern burn care. However, the heavy fluids and vascular access required may not be feasible ...in austere environments, mass casualty, or delayed transport scenarios. Enteral resuscitation has been proposed for these situations; we sought to examine the effectiveness of this strategy on improving burn-induced kidney injury. Anesthetized Yorkshire swine sustaining 40% TBSA full-thickness contact burns were randomized to three groups (n = 6/group): fluid deprivation, ad libitum water access, or 70 mL/kg/d Oral Rehydration Salt solution (ORS). Urine and blood were collected at baseline (BL), 6, 12, 24, 32, and 48h post-burn, at which point tissue was harvested and CT angiography performed. Although fluid consumption by ad libitum and ORS groups were matched (132±54mL/kg versus 120±24mL/kg, respectively), ORS intake increased urine output compared with water and no water (47.3±9.0 mL/kg versus 16.1±2.5 mL/kg, and 24.5±1.7 mL/kg respectively). Plasma creatinine peaked 6h following burn (1.67±0.07mg/dL) in all animals, but at 48h was comparable to BL in animals receiving water (1.23±0.06mg/dL) and ORS (1.30±0.09mg/dL), but not fluid deprived animals (1.56±0.05mg/dL) (P<0.05). Circulating levels of blood urea nitrogen steadily increased, but also decreased by 48h in animals receiving enteral fluids (P<0.05). Water deprivation reduced renal artery diameter (-1.4±0.17mm), whereas resuscitation with water (-0.44±0.14 mm) or ORS maintained it (-0.63±0.20 mm;P< 0.02). Circulating cytokines IL-1β, IL-6, IFNγ, and GM-CSF were moderately elevated in the fluid-deprived group. Taken together, the data suggest that enteral resuscitation with ORS rescues kidney function following burn injury. Incorporating enteral fluids may improve outcomes in resource-poor environments and possibly reduce IV fluid requirements to prevent co-morbidities associated with over-resuscitation. Studies into different volumes/types of enteral fluids are warranted. While ORS has saved many lives in cholera-associated dehydration, it should be investigated further for use in burn patients.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
ABSTRACT
In the current deployed environment, small teams are dispersed to provide damage control surgical capabilities within an hour of injury. Given the well-developed evacuation system, these ...teams do not typically have a significant patient hold capability. Improved understanding of the shortfalls and problems encountered when caring for combat casualties in prolonged care situations will facilitate improved manning, training, and equipping of these resource-limited teams. We present the case of two critically injured soldiers who were evacuated to a 10-person split Forward Surgical Team (FST) during a weather system that precluded further evacuation. The casualties underwent damage control procedures necessitating temporary abdominal closures. The FST had to organize itself to provide intensive care significantly longer than traditional timelines for this role of care. Additionally, most team members had scarce critical care experience. An after-action review confirmed that most team members felt that they had not received adequate pre-mission training in postoperative intensive care and were not comfortable managing ventilated patients. In the current mature theaters of operations, there are robust evacuation capabilities, and presentations of scenarios like that are rare. However, as combat casualty care becomes increasingly austere and remote, small surgical teams need to train and be equipped to provide care outside of normal operation and doctrinal limits, including robust team cross-training. Incorporating principles of the prolonged care of combat casualties into the training of military surgeons will improve preparedness for these challenging situations.
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DOBA, IZUM, KILJ, NUK, ODKLJ, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK, VSZLJ
BACKGROUND
The
Blue Book
, published in conjunction with the Military Health System Strategic Partnership with the American College of Surgeons, serves as a reference manual for institutions wishing ...to establish a military-civilian partnership (MCP). To evaluate the applicability of the criteria contained in the
Blue Book
, we created a survey to be distributed to MCP military surgeons and their civilian host champions.
METHODS
E-mail surveys were sent to MCP military surgeons and civilian host champions. Military surgeons were queried about basic demographic information and aspects of the MCP including type, duration of assignment, onboarding, malpractice coverage, and billing for services. We gathered information on the role of military surgeons at the MCP, workload information, and trauma cases. The civilian host champions survey focused on institutional activities including trauma surgical volume, clinical and educational opportunities for the military surgeons, and exposure to research. Military-civilian partnership military surgeons and civilian host champions were questioned on program attributes: administrative support, budget, and profile of the program within the institution.
RESULTS
Ten MCP military surgeons and 7 host champions completed surveys. The majority of military surgeons were assigned to the MCP for a 3-year instructor role (90%), and most were trauma surgeons (80%). Clinical activities for the military surgeon were where 60% spent ≥13 weeks annually on trauma. Military surgeons identified host program support in academic growth, deployment preparation, and sense of value at the MCP as positive attributes. Civilian host champions unanimously reported that exposure to research, opportunities to lead trauma teams, dedicated intensive care unit time, and patient volume were positive program attributes.
CONCLUSION
This preliminary survey demonstrates that the criteria put forth in the
Blue Book
align with experiences of MCP military surgeons and host champions. Continued development of this survey and others like it may be useful in the MCP program selection and evaluation process.
LEVEL OF EVIDENCE
Therapeutic/care management; Level V.
Objective:
To characterize humanitarian trauma care delivered by US military treatment facilities (MTFs) in Afghanistan and Iraq during combat operations.
Background:
International Humanitarian Law, ...which includes the Geneva Conventions, defines protections and standards of treatment to victims of armed conflicts. In 1949, these standards expanded to include injured civilians. In 2001, the Global War on Terror began in Afghanistan and expanded to Iraq in 2003. US MTFs provided care to all military forces, civilians, and enemy prisoners. A thorough understanding of the scope, epidemiology, resource requirements, and outcomes of civilian trauma in combat zones has not been previously characterized.
Methods:
Retrospective cohort analysis of the Department of Defense Trauma Registry from 2005 to 2019. Inclusion criteria were civilians and Non–North Atlantic Treaty Organization (NATO) Coalition Personnel (NNCP) with traumatic injuries treated at MTFs in Afghanistan and Iraq. Patient demographics, mechanism of injury, resource requirements, procedures, and outcomes were categorized.
Results:
A total of 29,963 casualties were eligible from the Registry. There were 16,749 (55.9%) civilians and 13,214 (44.1%) NNCP. The majority of patients were age above 13 years 26,853 (89.6%) and male 28,000 (93.4%). Most injuries were battle-related: 12,740 (76.1%) civilians and 11,099 (84.0%) NNCP. Penetrating trauma was the most common cause of both battle and nonbattle injuries: 12,293 (73.4%) civilian and 10,029 (75.9%) NNCP. Median Injury Severity Score (ISS) was 9 in each cohort with ISS≥25 in 2236 (13.4%) civilians and 1398 (10.6%) NNCP. Blood products were transfused to 35% of each cohort: 5850 civilians received a transfusion with 2118 (12.6%) of them receiving ≥10 units; 4590 NNCPs received a transfusion with 1669 (12.6%) receiving ≥10 units. MTF mortality rates were civilians 1263 (7.5%) and NNCP 776 (5.9%). Interventions, both operative and nonoperative, were similar between both groups.
Conclusions:
In accordance with International Humanitarian Law, as well as the US military’s medical rules of eligibility, civilians injured in combat zones were provided the same level of care as NNCP. Injured civilians and NNCP had similar mechanisms of injury, injury patterns, transfusion needs, and ISS. This analysis demonstrates resource equipoise in trauma care delivered to civilians and NNCP. Hospitals in combat zones must be prepared to manage large numbers of civilian casualties with significant human and material resources allocated to optimize survival. The provision of humanitarian trauma care is resource-intensive, and these data can be used to inform planning factors for current or future humanitarian care in combat zones.
Patients with burn shock can be challenging to resuscitate. Burn shock produces a variety of physiologic derangements: Patients are hypovolemic from volume loss, have a increased systemic vascular ...resistance, and may have a depressed cardiac output depending on the extent of the thermal injury. Additionally, the burn wound produces a significant inflammatory cascade of events that contributes to the shock state. Fluid resuscitation is foundational for the initial treatment of burn shock. Typical resuscitation is with intravenous lactated Ringer's in accordance with well‐established formulas based on burn wound size.
In the past century, as therapies to treat thermal injuries were being developed, plasma was the fluid used for burn resuscitation; in fact, plasma was used in World War II and throughout the 1950s and 1960s. Plasma was abandoned because of infectious risks and complications. Despite huge strides in transfusion medicine and the increased safety of blood products, plasma has never been readopted for burn resuscitation.
Over the past 15 years, there has been a paradigm shift in trauma resuscitation: Less crystalloid and more blood products are used; this strategy has demonstrated improved outcomes. Plasma is a physiologic fluid that stabilizes the endothelium. The endotheliopathy of trauma has been described and is mitigated by transfusion strategies with a 1:1 ratio of RBCs to plasma. Thermal injury also results in endothelial dysfunction: the endotheliopathy of burns. Plasma is likely a better resuscitation fluid for patients with significant burn wounds because of its capability to restore intravascular volume status and treat the endotheliopathy of burns.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
Whole blood can be ABO-type specific (TSWB) or Low-Titer O universal donor (LTOWB). Having previously used LTOWB, the US Armed Forces Blood Program began using TSWB in 1965 as a method of increasing ...the donor pool. In contrast to military practice, the AABB (Association for the Advancement of Blood and Biotherapies), from its first guidelines in 1958 until 2018, permitted only TSWB. Attempting to reduce time to transfusion, the US military reintroduced LTOWB in the deployed environment in 2015; this practice was endorsed by the AABB in 2018 and is progressively being implemented by military and civilian providers worldwide. LTOWB is the only practical solution prehospital. However, there are several reasons to retain the option of TSWB in hospitals with a laboratory. These include 1. as-yet ill-defined risks of immunological complications from ABO-incompatible plasma (even when this has low titres of anti A and B); 2. risks of high volumes of LTOWB including published historical advice (based on clinical experience) not to transfuse type-specific blood for 2-3 weeks following a substantial LTOWB transfusion; 3. uncertainty as to the optimal definition of "low titre"; and 4. expanding the potential donor pool by allowing type-specific transfusion. Several large randomised controlled trials currently underway are comparing LTOWB to component therapy, but none address the question of LTOWB vs. TSWB. There is sufficient data to suggest the additional risks of transfusing LTOWB to non-group O recipients should be avoided by using TSWB as soon as possible. Combined with the advantage of maintaining an adequate supply of blood products in times of high demand, this suggests retaining TSWB within the civilian and military blood supply system is desirable. TSWB should be preferred when patient blood group is confirmed in facilities with a hematology laboratory, with LTOWB reserved for patients whose blood group is unknown.
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