Experiences over the last three decades of war have demonstrated a high incidence of traumatic brain injury (TBI) resulting in a persistent need for a neurosurgical capability within the deployed ...theater of operations. Despite this, no doctrinal requirement for a deployed neurosurgical capability exists. Through an iterative process, the Joint Trauma System Committee on Surgical Combat Casualty Care (CoSCCC) developed a position statement to inform medical and nonmedical military leaders about the risks of the lack of a specialized neurosurgical capability.
The need for deployed neurosurgical capability position statement was identified during the spring 2021 CoSCCC meeting. A triservice working group of experienced forward-deployed caregivers developed a preliminary statement. An extensive iterative review process was then conducted to ensure that the intended messaging was clear to senior medical leaders and operational commanders. To provide additional context and a civilian perspective, statement commentaries were solicited from civilian clinical experts including a recently retired military trauma surgeon boarded in neurocritical care, a trauma surgeon instrumental in developing the Brain Injury Guidelines, a practicing neurosurgeon with world-renowned expertise in TBI, and the chair of the Committee on Trauma.
After multiple revisions, the position statement was finalized, and approved by the CoSCCC membership in February 2023. Challenges identified include (1) military neurosurgeon attrition, (2) the lack of a doctrinal neurosurgical capabilities requirement during deployed combat operations, and (3) the need for neurosurgical telemedicine capability and in-theater computed tomography scans to triage TBI casualties requiring neurosurgical care.
Challenges identified regarding neurosurgical capabilities within the deployed trauma system include military neurosurgeon attrition and the lack of a doctrinal requirement for neurosurgical capability during deployed combat operations. To mitigate risk to the force in a future peer-peer conflict, several evidence-based recommendations are made. The solicited civilian commentaries strengthen these recommendations by putting them into the context of civilian TBI management. This neurosurgical capabilities position statement is intended to be a forcing function and a communication tool to inform operational commanders and military medical leaders on the use of these teams on current and future battlefields.
Prognostic and Epidemiological; Level V.
Background Standard hemodynamic evaluation of patients in shock may underestimate severity of hemorrhage given physiologic compensation. Blood lactate (BL) is an important adjunct in characterizing ...shock, and point-of-care devices are currently available for use in the prehospital (PH) setting. The objective of this study was to determine if BL levels have better predictive value when compared with systolic blood pressure (SBP) for identifying patients with an elevated risk of significant transfusion and mortality in a hemodynamically indeterminant cohort. Study Design We selected trauma patients admitted to a level I trauma center over a 9-year period with SBP between 90 and 110 mmHg. The predictive capability of initial emergency department (ED) BL for needing ≥6 units packed RBCs within 24 hours postinjury and mortality was compared with PH-SBP and ED-SBP by comparing estimated area under the receiver operator curve (AUC). Results We identified 2,413 patients with ED-SBP and 787 patients with PH-SBP and ED-BL. ED-BL was statistically better than PH-SBP (p = 0.0025) and ED-SBP (p < 0.0001) in predicting patients who will need ≥ 6 U packed RBCs within 24 hours postinjury (AUC: ED-BL, 0.72 vs PH-SBP, 0.61; ED-BL, 0.76 vs ED-SBP, 0.60). ED-BL was also a better predictor than both PH-SBP (p = 0.0235) and ED-SBP (p < 0.0001) for mortality (AUC: ED-BL, 0.74 vs PH-SBP, 0.60; ED-BL, 0.76 vs ED-SBP, 0.61). Conclusions ED-BL is a better predictor than SBP in identifying patients requiring significant transfusion and mortality in this cohort with indeterminant SBP. These findings suggest that point-of-care BL measurements could improve trauma triage and better identify patients for enrollment in interventional trials. Further studies using BL measurement in the PH environment are warranted.
Background Trauma is the leading cause of death among North Americans between the ages of 1 and 44 years. Resuscitation with hypertonic saline (7.5%) solutions can reduce mortality in hypotensive and ...brain-injured patients. Study Design Two multicenter, randomized, clinical trials were designed to compare hypertonic saline resuscitation with or without dextran with conventional isotonic resuscitation in patients with hypovolemic shock or traumatic brain injury. During a 3-year period, 5,848 patients will be randomized, with a primary end point of 28-day survival in the hypovolemic shock cohort and 6-month neurologic outcomes in the traumatic brain injury cohort. Results This is a report of the study design and implementation of 2 large-scale prehospital intervention trials from the Resuscitation Outcomes Consortium that qualify for exception from informed consent required for emergency research outlined in FDA regulation 21CFR50.24 and the Canadian Tri-Council Agreement for research in emergency health situations (Article 2.8). Conclusions We have successfully designed and implemented two prehospital intervention trials. The proc-ess has helped define the numerous challenges that must be overcome to pursue exception from informed consent resuscitation research in the prehospital setting. The results of these studies will hopefully advance and improve the early care of the severely injured patient.
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GEOZS, NUK, OILJ, SBCE, SBJE, UL, UPUK
Abstract Background Pressure ulcers are a costly hospital-acquired condition in terms of clinical outcome and expense. The Braden Scale was developed in 1987 as a risk scoring method for pressure ...ulcers and uses six different risk factors: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. A score of ≤18 is considered high risk. To date, research on the utility of the Braden Scale has focused on general medicine and nontrauma/burn surgery patients. We hypothesize that the Braden Scale does not accurately discriminate who will get a pressure ulcer among trauma and burn patients. Methods We collected data from medical records regarding documented Braden scores and presence of pressure ulcers regardless of staging. Patients with ulcers present on admission were excluded from analysis. For each patient, the lowest Braden score documented before the occurrence of the pressure ulcer was determined. A logistic regression was used to estimate odds ratios and associated 95% confidence intervals for the association between pressure ulcer likelihood and lowest Braden Scale measurement. To determine the discriminatory ability of the Braden Scale on pressure ulcer risk, four measures of performance (i.e., sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio) were calculated for four nonmutually exclusive groups: a Braden Scale measurement ≤18, ≤14, ≤12, and ≤9. Results From 2011 through 2014, a total of 2660 patients were admitted to the trauma/burn intensive care unit. Of these patients, 63 (2.3%) subsequently developed a pressure ulcer. A Braden Scale of ≤18 as the threshold for being at-risk of pressure ulcer had a sensitivity of 100% and specificity of 6%, whereas a Braden Scale of ≤9 had a sensitivity of 28.6% and a specificity of 90%. For all Braden Scale measurements, the positive likelihood ratio never reached the value of 10 that suggests high likelihood of an ulcer. Conclusions The Braden scale has mediocre discriminatory ability among the trauma/burn population. In addition, the low positive likelihood ratio suggests that the Braden scale may not be a useful clinical tool as it may result in unnecessary expenditure of time and personnel resources in preventing pressure ulcer formation.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
External mechanical forces can cause ventricular capture and fibrillation (i.e., commotio cordis). In animals, we showed that chest compressions (CCs) can also cause the phenomenon. The aim of the ...present study was to determine whether ventricular capture by CCs occurs in humans. Electronic rhythm strips were analyzed in 31 cases of out-of-hospital cardiac arrest. The timing of the CCs was identified from the changes in thoracic impedance between the defibrillator pads. Ventricular capture was defined as QRS complexes of similar morphology occurring intermittently but synchronized with the CC artifact and impedance waveform. Only intermittent ventricular capture was identified to avoid misclassifying constant motion artifacts or intrinsic rhythm as ventricular capture. Of the 29 patients who received CCs for ≥1 minute, minimal or stable motion artifact was present in 24. Intermittent ventricular capture was found in 7 of the 24 patients. In the patients with ventricular capture, the number of ventricular activations (from ventricular capture and native beats) was greater during the CCs than when the CCs was not being performed (18 ± 8.9 vs 9.7 ± 4.0 activations in 15 seconds, p = 0.01). However, in patients without ventricular capture, they were similar (6.8 ± 8.2 vs 7.2 ± 8.8 activations in 15 seconds, p = 0.47). Refibrillation occurred in 22 patients; it began during the CCs in 16 and closely following their initiation in 3. In conclusion, CCs during cardiopulmonary resuscitation can electrically stimulate the heart. Additional studies evaluating the effect of ventricular capture on cardiopulmonary resuscitation outcomes, its relation to refibrillation, and methods to prevent or time ventricular capture by CCs are warranted.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Background Training of emergency procedures is challenging and application is not routine in all health care settings. The debate over simulation as an alternative to live tissue training continues ...with legislation before Congress to banish live tissue training in the Department of Defense. Little evidence exists to objectify best practice. We sought to evaluate live tissue and simulation-based training practices in 12 life-saving emergency procedures. Methods In the study, 742 subjects were randomized to live tissue or simulation-training. Assessments of self-efficacy, cognitive knowledge, and psychomotor performance were completed pre- and post-training. Affective response to training was assessed through electrodermal activity. Subject matter experts gap analysis of live tissue versus simulation completed the data set. Results Subjects demonstrated pre- to post-training gains in self-efficacy, cognitive knowledge, psychomotor performance, and affective response regardless of training modality ( P < .01 each). With the exception of fluid resuscitation in the psychomotor performance domain, no statistically significant differences were observed based on training modality in the overall group. Risk estimates on the least pretest performance subgroup favored simulation in 7 procedures. Affective response was greatest in live tissue training ( P < .01) and varied by species and model. Subject matter experts noted significant value in live tissue in 7 procedures. Gap analysis noted shortcomings in all models and synergy between models. Conclusion Although simulation has made significant gains, no single modality can be identified definitively as superior. Wholesale abandonment of live tissue training is not warranted. We maintain that combined live tissue and simulation-based training add value and should be continued. Congressional mandates may accelerate simulation development and improve performance.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Objectives:. Determine associations between biomarkers of endotheliopathy, 24-hour fibrinolysis phenotypes and clinical outcomes after trauma. Background:. The vascular endothelium is a critical ...regulator of hemostasis and organ function. The relationship between markers of endotheliopathy and fibrinolysis following trauma has not been evaluated. Methods:. We performed a secondary analysis of prospectively collected biomarker data in the Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) randomized controlled trial. We stratified subjects by 24-hour thromboelastography (TEG) percent clot lysis (LY30) and plasma d-dimer (DD) levels and evaluated differences in endotheliopathy biomarkers and clinical outcomes between subjects with one of four 24-hour fibrinolysis phenotypes: LY30 0.9% to 2.9% (LY30norm), LY30 > 2.9% (LY30high), LY30 < 0.9% and low DD (LY30low+DDlow), and LY30 < 0.9% and high DD (LY30low+DDhigh). Results:. The analysis included 168 subjects with LY30norm, 32 with LY30high, 147 with LY30low+DDlow, and 124 with LY30low+DDhigh. LY30low+DDhigh subjects had greater injury severity and a higher incidence of severe head injury, multiorgan failure (MOF), and mortality than the other phenotypes. All endotheliopathy biomarkers were significantly higher in the LY30low+DDhigh phenotype. Adjusting for injury severity, mechanism, and head trauma, 24-hour angiopoietin-2 and soluble thrombomodulin were independently associated with the LY30low+DDhigh phenotype. Both endothelial biomarkers were discriminating for MOF. Subjects with thrombomodulin level >9.5 ng/mL and angiopoietin-2 level >3.6 ng/mL accounted for 64% of subjects who developed MOF. Conclusions:. In a multicenter trauma cohort, subjects with a fibrinolysis phenotype characterized by low TEG lysis and elevated DD 24 hours after injury have significantly worse endotheliopathy and clinical outcomes. Our findings support mechanistic evaluations of the role of the endothelium in fibrinolysis dysregulation that may drive late-stage organ injury.
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