The Beirut Port Explosion of 4 August 2020 posed significant medical challenges for relief teams and caused diverse blast injuries to individuals in the area. Several days after the explosion occurred, a Special Operations Forces (SOF) medic provided care for a Servicemember who developed neurologic symptoms that led to his medical evacuation out of Lebanon. These relief efforts underscore the need for vigilant post-blast monitoring and consideration of long-term consequences.
Introduction: Under normal conditions, the use of a supraglottic airway device (SAD) is safe and effective. There are situations in military environments in which such devices must be used in the dark (e.g., to conceal the team's position). The aim of our study was to evaluate the use of different SADs using night vision goggles (NVG) on a manikin.
Methods: A group of 53 medically trained soldiers (paramedics, emergency medical technicians [EMTs] and Combat First Responders Bravo) was given a brief demonstration of how to place three different types of SAD in a manikin's airway. This was followed by randomized use in ambient light and then, after the room was darkened, with NVG. Differences in terms of placement success, placement time, and observed usage problems were compared.
Results: Attempt success rates were >91% for all SADs used both in ambient light and with NVG. Median placement times differed significantly between ambient light and NVG (ambient light/NVG: i-gel, 7.2/15.1s; standard laryngeal mask airway [LMA], 15.4/21.5s; laryngeal tube [LT], 13.4/24.3s). In the direct comparison of the various SADs, the i-gel laryngeal mask airway was placed significantly faster than a standard LMA (P<.0001) and the LT (P<.0001).
Conclusions: Our study proves that the use of NVG has a measurable impact on the speed of placement but does not prolong placement to a clinically significant extent on a manikin. In addition, there was no significant difference in the placement success for each SAD in ambient light or with NVG. Furthermore, all participants were able to read the size information on the various SADs when wearing NVG and were thus able to make a proper size selection. It would, however, make use easier if additional size markings were added. SADs can be applied quickly and safely on the manikin even when NVG are worn. Differences in the use of the various types of SAD are not relevant from a clinical perspective. Using NVG while placing a SAD seems to be safe for the patient and might increase safety for the care provider in tactical situations by maintaining concealment in dark environments.
Traumatic ocular injuries from both combat- and noncombat-related activity remain a significant burden in active duty Ser- vicemembers and present a diagnostic and therapeutic challenge to Special Operations medics with limited resources in far forward and remote areas. Blunt ocular injury, whether from sports or battlefield engagement, can result in a variety of eyesight-threatening injuries, including hyphema, commotio retinae, iritis, uveitis, and open globe injury. The management of these conditions often requires teleconsultation with ophthalmology and potential evacuation, which is tailored to the resources available for the Special Operations Forces medic. The authors present a case of sports-related traumatic hyphema complicated by commotio retinae in a Special Operations unmanned aircraft systems (UAS) operator, requiring teleconsultation and evacuation to specialty care. The authors additionally provide tailored prehospital strategies for the management of these unique but imperative injuries.
Posttraumatic stress can result from combat and noncombat-related experiences. Conditioning military forces to be lethal or to save lives may influence responses to stress. Training to respond to casualties and to save lives should be a universal practice among medical and non-medical personnel when preparing for combat operations and battlefield casualties. National security requires a strong military. A strong military is reliant on a strong society that is cohesive as well as economically and spiritually intact. Cohesion is vital to the overall health and development of a society. A lack of cohesion can result in excess mortality and a reduction in life expectancy. Cohesion expands social networks and increases social capital that provides support for its military and overall population. Cohesion and leadership are needed to defend our nation, preserve national security, improve societal health, and save lives.
Posttraumatic stress disorder (PTSD)/blast traumatic brain injury (bTBI) in a Special Operations Forces (SOF) cohort has been shown to be successfully treated using a cervical sympathetic blockade (CSB)/ketamine infusion (KI) combination, termed the SOF method. In a prior case report, the patient was followed for 1 year. This report followed the same patient for a total of 720 days and found prolonged and sustained benefits with respect to PTSD and bTBI symptoms with further application of the SOF method.
Background: Special Operations Forces (SOF) have become the solution to many of the United States military challenges due to their ability to conduct time sensitive, clandestine, and high-risk missions. Historically, SOF were assumed to be resilient to the psychological sequelae of war, including posttraumatic stress disorder (PTSD). However, the objective burden of PTSD in SOF, particularly after traumatic brain injury (TBI), remains unknown. This study compared average PTSD symptoms over time between SOF and Conventional Forces (CF) who had sustained a TBI.
Methods: This prospective cohort study examined Servicemembers and Veterans admitted to one of five Veterans Affairs Polytrauma Rehabilitation Centers for TBI. Propensity score matching created matched samples of 205 SOF and 205 CF. The PTSD Checklist-Civilian version (PCL-C) measured PTSD symptoms at admission and 1, 2, 5, and 10 years post TBI.
Results: In a longitudinal mixed-effects model of PTSD symptoms over time grouped by TBI severity, SOF and CF had similar severity and patterns of PTSD symptoms. SOF and CF with mild TBI had more PTSD symptoms across all time points compared to those with moderate and severe TBI.
Conclusion: The evolution and severity of PTSD symptoms after TBI in SOF and CF were similar. While SOFs had higher resilience compared to CFs in previous work, SOFs are not impervious to trauma exposure and PTSD. Increasing awareness of PTSD prevalence and consequences is needed to serve SOF. Identifying those needing care and providing evidence-based PTSD treatments can have the downstream effects of reducing attrition from the service and maintaining military readiness.
Tactical Combat Casualty Care (TCCC) has been designated by the U.S. Department of Defense as the military standard for battlefield trauma care. The TCCC Guidelines are a set of evidence-based, best-practice recommendations for combat medical personnel to use in caring for casualties on the battlefield prior to their arrival at a medical treatment facility. In 2024, the Committee on TCCC approved a change to the recommended management of the airway in TCCC. This change to the TCCC Guidelines does the following: - Continues the recommendation for use of the "Sit-Up and Lean-Forward" positioning to keep the airway clear in casualties with direct maxillofacial trauma when the casualties are conscious and able to do so. - Recommends the removal of the extraglottic airway as an airway adjunct. - Recommends that casualties who are unconscious but do not have a traumatic airway obstruction be placed in the recovery position with the chin tilted away from the chest. There is no longer a recommendation to use the "jaw thrust." - Recommends the removal of the Control-Cric as the preferred cricothyroidotomy device. - Recommends continuous capnography monitoring for casualties who have a cricothyroidotomy performed, in order to provide initial and ongoing assurance that the cricothyrotomy tube is positioned correctly. - Adds an oxygenation and ventilatory support note at the end of the respiratory/breathing section of Tactical Field Care. - Adds a recommendation in the Respirations/Breathing section that in the case of impaired ventilation and uncorrectable hypoxia with an oxygen saturation less than 90%, a properly sized nasopharyngeal airway should be considered when performing bag valve mask ventilations. - Adds a recommendation in the Respirations/Breathing section that states that in the case of impaired ventilation and uncorrectable hypoxia with an oxygen saturation less than 90%, the casualty should be ventilated with a 1,000mL resuscitator bag valve mask. - Removes recommendations for airway management in the Tactical Evacuation Care phase of care, as responsibility for that phase of care has been shifted to the Committee on Enroute Combat Casualty Care.
Background: Fresh whole blood (FWB) is essential for hemorrhagic shock resuscitation, but little literature evaluates medics ability to obtain intravenous (IV) access. Options for IV access include a 16-gauge hypodermic needle attached to the FWB collection bag (straight stick technique [SST]) and an 18-gauge angiocatheter with a saline lock (saline lock technique [SLT]), which may improve access given its confirmatory flash chamber and medic familiarity.
Methods: In a prospective, randomized, crossover study, a convenience sample of U.S. Army medics performing FWB transfusion training initiated IV access with SST or SLT for FWB collection to achieve the minimum transfusable volume of 527g. The primary outcome was seconds to achieve minimum transfusable volume. Secondary outcomes included first-attempt IV access success and end-user feedback.
Results: Eighteen medics demonstrated a shorter median time to reach the minimum transfusable volume with SST (819.36 [IQR 594.40-952.30] sec) compared with SLT (1148.43 [IQR 890.90-1643.70] sec, P=.002). No sequence or period effects occurred. Compared with SLT, SST demonstrated higher first-attempt IV access success (18, 78% versus 11, 48%; P=.037). Accordingly, most medics reported SLT would perform worse than SST for FWB collection and IV access in tactical environments.
Conclusions: Medics achieved minimum transfusable volume faster and higher first-attempt IV access success with SST than SLT. Future studies should compare a 16-gauge SLT and SST, and further evaluate IV access techniques for improved evaluation of medic skills.
Pneumothorax resulting from injury is a common phenomenon in both civilian and military trauma. A pneumothorax or simple pneumothorax is defined as air in the pleural space. A tension pneumothorax can evolve from a simple pneumothorax if there is a continued air leak from the lung without mechanism for egress. This occurs due to an expanding air volume and pressure in the pleural space. The tension pneumothorax results in obstructive shock that may be a life-threatening emergency. All types of pneumothorax can occur in patients who are non-positive pressure ventilated as well as those receiving positive pressure ventilation. Positive pressure ventilation changes the dynamics of pneumothoraces in that it can exacerbate an air leak, resulting in a simple pneumothorax evolving into a tension pneumothorax. The pathophysiology and clinical presentation of these traumatic conditions represent two differing sub-pathologies, and, although they share the same underlying physiological process in the opinion of the authors, a different approach should be adopted when considering treatment. The objective of this manuscript is to discuss the etiology, incidence, and clinical significance of simple and tension pneumothoraces. This paper will propose a uniform description of pathophysiology and diagnostic elements as well as treatment strategies. The intent is to provide a standardization of the nomenclature as well as an understanding of the physiology and clinical significance of the spectrum of pneumothoraces. Finally, we conclude with the author groups 16-point position statement on traumatic tension pneumothorax, its definition and management. The main author position is: - In spontaneously breathing tension pneumothorax, because of the risk of harm, suspected low incidence, high rate of misdiagnosis, and low rate of procedural success, a conservative approach is advised. - In positive pressure ventilated tension pneumothorax, the incidence is greater and the time to severe physiological impact shorter; thus a more aggressive approach is advised.
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