IMPORTANCE: The term golden hour was coined to encourage urgency of trauma care. In 2009, Secretary of Defense Robert M. Gates mandated prehospital helicopter transport of critically injured combat ...casualties in 60 minutes or less. OBJECTIVES: To compare morbidity and mortality outcomes for casualties before vs after the mandate and for those who underwent prehospital helicopter transport in 60 minutes or less vs more than 60 minutes. DESIGN, SETTING, AND PARTICIPANTS: A retrospective descriptive analysis of battlefield data examined 21 089 US military casualties that occurred during the Afghanistan conflict from September 11, 2001, to March 31, 2014. Analysis was conducted from September 1, 2014, to January 21, 2015. MAIN OUTCOMES AND MEASURES: Data for all casualties were analyzed according to whether they occurred before or after the mandate. Detailed data for those who underwent prehospital helicopter transport were analyzed according to whether they occurred before or after the mandate and whether they occurred in 60 minutes or less vs more than 60 minutes. Casualties with minor wounds were excluded. Mortality and morbidity outcomes and treatment capability–related variables were compared. RESULTS: For the total casualty population, the percentage killed in action (16.0% 386 of 2411 vs 9.9% 964 of 9755; P < .001) and the case fatality rate (CFR 13.7 469 of 3429 vs 7.6 1344 of 17 660; P < .001) were higher before vs after the mandate, while the percentage died of wounds (4.1% 83 of 2025 vs 4.3% 380 of 8791; P = .71) remained unchanged. Decline in CFR after the mandate was associated with an increasing percentage of casualties transported in 60 minutes or less (regression coefficient, –0.141; P < .001), with projected vs actual CFR equating to 359 lives saved. Among 4542 casualties (mean injury severity score, 17.3; mortality, 10.1% 457 of 4542) with detailed data, there was a decrease in median transport time after the mandate (90 min vs 43 min; P < .001) and an increase in missions achieving prehospital helicopter transport in 60 minutes or less (24.8% 181 of 731 vs 75.2% 2867 of 3811; P < .001). When adjusted for injury severity score and time period, the percentage killed in action was lower for those critically injured who received a blood transfusion (6.8% 40 of 589 vs 51.0% 249 of 488; P < .001) and were transported in 60 minutes or less (25.7% 205 of 799 vs 30.2% 84 of 278; P < .01), while the percentage died of wounds was lower among those critically injured initially treated by combat support hospitals (9.1% 48 of 530 vs 15.7% 86 of 547; P < .01). Acute morbidity was higher among those critically injured who were transported in 60 minutes or less (36.9% 295 of 799 vs 27.3% 76 of 278; P < .01), those severely and critically injured initially treated at combat support hospitals (severely injured, 51.1% 161 of 315 vs 33.1% 104 of 314; P < .001; and critically injured, 39.8% 211 of 530 vs 29.3% 160 of 547; P < .001), and casualties who received a blood transfusion (50.2% 618 of 1231 vs 3.7% 121 of 3311; P < .001), emphasizing the need for timely advanced treatment. CONCLUSIONS AND RELEVANCE: A mandate made in 2009 by Secretary of Defense Gates reduced the time between combat injury and receiving definitive care. Prehospital transport time and treatment capability are important factors for casualty survival on the battlefield.
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.
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.
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.
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 combat casualties 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.
The US Army pioneered medical evacuation (MEDEVAC) by helicopter, yet its system remains essentially unchanged since the Vietnam era. Care is provided by a single combat medic credentialed at the ...Emergency Medical Technician - Basic level. Treatment protocols, documentation, medical direction, and quality improvement processes are not standardized and vary significantly across US Army helicopter evacuation units. This is in contrast to helicopter emergency medical services that operate within the United States. Current civilian helicopter evacuation platforms are routinely staffed by critical care-trained flight paramedics (CCFP) or comparably trained flight nurses who operate under trained EMS physician medical direction using formalized protocols, standardized patient care documentation, and rigorous quality improvement processes. This study compares mortality of patients with injury from trauma between the US Army's standard helicopter evacuation system staffed with medics at the Emergency Medical Technician - Basic level (standard MEDEVAC) and one staffed with experienced CCFP using adopted civilian helicopter emergency medical services practices.
This is a retrospective study of a natural experiment. Using data from the Joint Theater Trauma Registry, 48-hour mortality for severely injured patients (injury severity score ≥ 16) was compared between patients transported by standard MEDEVAC units and CCFP air ambulance units.
The 48-hour mortality for the CCFP-treated patients was 8% compared to 15% for the standard MEDEVAC patients. After adjustment for covariates, the CCFP system was associated with a 66% lower estimated risk of 48-hour mortality compared to the standard MEDEVAC system.
These findings demonstrate that using an air ambulance system based on modern civilian helicopter EMS practice was associated with a lower estimated risk of 48-hour mortality among severely injured patients in a combat setting.
Historical review of emergency tourniquet use to stop bleeding Kragh, John F., Col., M.C., U.S.A., M.D; Swan, Kenneth G., Col. (ret.), M.C., U.S.A.R., M.D; Smith, Dale C., Ph.D ...
The American journal of surgery,
02/2012, Letnik:
203, Številka:
2
Journal Article
Recenzirano
Abstract Background Although a common first aid topic, emergency tourniquets to stop bleeding are controversial because there is little experience on which to guide use. Absent an adequate historical ...analysis, we have researched development of emergency tourniquets from antiquity to the present. Methods We selected sources emphasizing historical development of tourniquets from books and databases such as PubMed. Results The history of the emergency tourniquet is long and disjointed, mainly written by hospital surgeons with little accounting, until recently, of the needs of forward medics near the point injury. Many investigators often are unaware of the breadth of the tourniquet’s history and voice opinions based on anecdotal observations. Conclusions Reporting the historical development of tourniquet use allowed us to recognize disparate problems investigators discuss but do not recognize, such as venous tourniquet use. We relate past observations with recent observations for use by subsequent investigators.
We describe facile isolation of full-length IgG antibodies from combinatorial libraries expressed in E. coli. Full-length heavy and light chains are secreted into the periplasm, where they assemble ...into aglycosylated IgGs that are captured by an Fc-binding protein that is tethered to the inner membrane. After permeabilizing the outer membrane, spheroplast clones expressing so-called E-clonal antibodies, which specifically recognize fluorescently labeled antigen, are selected using flow cytometry. Screening of a library constructed from an immunized animal yielded several antibodies with nanomolar affinities toward the protective antigen of Bacillus anthracis.
Celotno besedilo
Dostopno za:
DOBA, IJS, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Study objective The CricKey is a novel surgical cricothyroidotomy device combining the functions of a tracheal hook, stylet, dilator, and bougie incorporated with a Melker airway cannula. This study ...compares surgical cricothyroidotomy with standard open surgical versus CricKey technique. Methods This was a prospective crossover study using human cadaveric models. Participants included US Army combat medics credentialed at the emergency medical technician–basic level. After a brief anatomy review and demonstration, participants performed in random order standard open surgical cricothyroidotomy and CricKey surgical cricothyroidotomy. The primary outcome was first-pass success, and the secondary outcome measure was procedural time. Results First-attempt success was 100% (15/15) for CricKey surgical cricothyroidotomy and 66% (10/15) for open surgical cricothyroidotomy (odds ratio 16.0; 95% confidence interval 0.8 to 326). Surgical cricothyroidotomy insertion was faster for CricKey than open technique (34 versus 65 seconds; median time difference 28 seconds; 95% confidence interval 16 to 48 seconds). Conclusion Compared with the standard open surgical cricothyroidotomy technique, military medics demonstrated faster insertion with the CricKey. First-pass success was not significantly different between the techniques.
The US Army medical evacuation (MEDEVAC) community has maintained a reputation for high levels of success in transporting casualties from the point of injury to definitive care. This work served as a ...demonstration project to advance a model of quality assurance surveillance and medical direction for prehospital MEDEVAC providers within the Joint Trauma System.
A retrospective interrupted time series analysis using prospectively collected data was performed as a process improvement project. Records were reviewed during two distinct periods: 2009 and 2014 to 2015. MEDEVAC records were matched to outcomes data available in the Department of Defense Trauma Registry. Abstracted deidentified data were reviewed for specific outcomes, procedures, and processes of care. Descriptive statistics were applied as appropriate.
A total of 1,008 patients were included in this study. Nine quality assurance metrics were assessed. These metrics were: airway management, management of hypoxemia, compliance with a blood transfusion protocol, interventions for hypotensive patients, quality of battlefield analgesia, temperature measurement and interventions, proportion of traumatic brain injury (TBI) patients with hypoxemia and/or hypotension, proportion of traumatic brain injury patients with an appropriate assessment, and proportion of missing data. Overall survival in the subset of patients with outcomes data available in the Department of Defense Trauma Registry was 97.5%.
The data analyzed for this study suggest overall high compliance with established tactical combat casualty care guidelines. In the present study, nearly 7% of patients had at least one documented oxygen saturation of less than 90%, and 13% of these patients had no documentation of any intervention for hypoxemia, indicating a need for training focus on airway management for hypoxemia. Advances in battlefield analgesia continued to evolve over the period when data for this study was collected. Given the inherent high-risk, high-acuity nature of prehospital advanced life support and emphasis on the use of nonphysician practitioners in an out-of-hospital setting, the need for ongoing medical oversight and quality improvement assessment is crucial.
Care management, level IV.
Avoiding Common Prehospital Errors Mabry, Robert L., MD
Annals of Emergency Medicine,
January 2014, Letnik:
63, Številka:
1
Journal Article, Book Review
Historical review of modern military conflicts suggests that airway compromise accounts for 1?2% of total combat fatalities. This study examines the specific intervention of pre-hospital ...cricothyrotomy (PC) in the military setting using the largest studies of civilian medics performing PC as historical controls. The goal of this paper is to help define optimal airway management strategies, tools and techniques for use in the military pre-hospital setting.
This retrospective chart review examined all patients presenting to combat support hospitals following prehospital cricothyrotomy during combat operations in Iraq and Afghanistan during a 22-month period. A PC was determined ?successful? if it was documented as functional on arrival to the hospital. All PC complications that were documented in the patients? record were also noted in the review.
Two thirds of the patients died. The most common injuries were caused by explosions, followed by gunshot wounds (GSW) and blunt trauma. Eighty-two percent of the casualties had injures to face, neck or head. Those injured by gunshot wounds to the head or thorax all died. The largest group of survivors had gunshot wounds to the face and/or neck (38%) followed by explosion related injury to the face, neck and head (33%). Pre-hospital cricothyrotomy was documented as successful in 68% of the cases while 26% of the PC?s failed to cannulate the trachea. In 6% of cases the patient was pronounced dead on arrival without documentation of PC function. The majority of PC?s (62%) were performed by combat medics at the point of injury. Physicians and physician assistants (PA) were more successful performing PC than medics with a 15% versus a 33% failure rate. Complications were not significantly different than those found in civilian PC studies, including incorrect anatomic placement, excessive bleeding, air leak and right main stem placement.
The majority of patients who underwent PC died (66%). The largest group of survivors had gunshot wounds to the face and/or neck (38%) followed by explosion related injury to the face, neck and head (33%). Military medics have a 33% failure rate when performing this procedure compared to 15% for physicians and physician assistants. Minor complications occurred in 21% of cases. The survival rate and complication rates are similar to previous civilian studies of medics performing PC. However the failure rate for military medics is three to five times higher than comparable civilian studies. Further study is required to define the optimal equipment, technique, and training required for combat medics to master this infrequently performed but lifesaving procedure.
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