Journal of special operations medicine : a peer reviewed journal for SOF medical professionals最新文献

Calcium is vital for coagulation and hemodynamic stability, with hypocalcemia correlating to higher mortality in trauma patients. Trauma-induced hypocalcemia is a critical issue in battlefield medicine, affecting both coagulation and cardiovas-cular function in severely injured individuals by exacerbating the effects of the lethal triad. TCCC is based on strategies to prevent and manage hemorrhage and shock, including the use of blood products and the administration of calcium to avoid citrate toxicity. However, there remains debate about whether calcium supplementation should be universally recommended, even in scenarios where blood products are unavailable. This paper examines evidence surrounding the inclusion of cal-cium in military trauma care protocols, weighing the benefits against potential risks and challenges.

Background: The Belgian Defense introduced an integrative and immersive model of an educational program in 2021 specifically dedicated to combat medic certification. The primary objective of the study was to compare final theoretical and practical results between emergency medical technician (EMT) and non-EMT candidates.

Methods: This longitudinal cohort monocentric study, conducted in 2021 and 2022, analyzed all theoretical and practical examination results collected by the instructors, evaluators and Exercise Controllers. Two main domains (theoretical and practical total scores) and three sub-domains (MED LEADER, MED PROVIDER, TAC LEADER) were specifically explored.

Results: One hundred thirty-seven combat medic candidates for an advanced EMT certification were recruited, with a mean age of 30.3 years and a mean seniority of 8.9 years. Clinically naïve, non-EMT candidates represented 62.8% of the population. Clinically exposed EMT candidates did not demonstrate superiority in any domains or subdomains when compared to non-EMT candidates.

Discussion: Some intrinsic parameters of the course could explain the non-superiority of the clinically exposed group. Compensating intrinsic motivation and situational awareness should be further explored in the clinically naïve group.

Conclusion: Non-EMT candidates were able to score robustly, similar to their EMT counterparts, in an integrative, hyper-realistic, and immersive course promoting multilevel processing.

We describe an Army Officer with infectious endocarditis af-ter being hospitalized with a heat injury while participating in Special Forces Assessment and Selection. A 26-year-old other-wise healthy male presented with a fever, skin lesions, and pain at his IV site after a recent hospitalization. He was admitted on intravenous antibiotics due to suspicion of bacteremia and was eventually diagnosed with MRSA endocarditis. The pa-tient required months of antibiotics and left brachial vein exci-sion for source control. After multiple readmissions for MRSA bacteremia over the following 2 years, the patient was placed on daily prophylactic doxycycline. Due to complications from his condition, the patient was medically retired from the Army. When the tactical setting allows, prehospital providers must practice aseptic techniques and advocate for their patients when other providers lack awareness of the impact of field environments.

Objectives: Low fibrinogen contributes to poor outcomes in patients with traumatic coagulopathy. Empiric fibrinogen replacement is not supported. Early identification of patients at high risk of hypofibrinogenemia may enable targeted support. We sought to identify prehospital variables associated with hypofibrinogenemia at emergency department (ED) arrival.

Methods: We retrospectively reviewed health records (January 2015 to August 2019) of consecutive patients transported by helicopter EMS to two trauma centers who received one or more units of packed red blood cells (pRBCs) during transport. The primary outcome was first ED fibrinogen level transformed into a binomial variable (<1.6g/L or ≥1.6g/L) for the 65 patients analyzed. Direct multivariable logistic regression examined the independent variables (hypotension, shock index (SI), and systolic blood pressure). Odds ratios and 95% CIs were reported.

Results: Hypotension after first pRBC transfusion was significantly associated with low ED first fibrinogen level, P=.03, with 6.6 (1.1-40.15) times greater odds of fibrinogen <1.6g/L. Hypotension post-transfusion was also associated with ED first international normalized ratio (INR) >1.5, P=.013, with those cases having 17.5 (1.8-169.2) greater odds of INR >1.5. Additionally, an EDSI ≥1.5 had 8.9 (1.9-42.6) times greater odds of fibrinogen <1.6g/L than those with an EDSI <1, P=.006. Compared with the EDSI 1-1.49 group, those with an EDSI ≥1.5 had 6.9 times greater odds of having fibrinogen <1.6g/L, P=.02, OR=6.9 (1.3-36.1).

Conclusion: In major trauma patients transported by helicopter EMS, persistent hypotension after the first blood transfusion and an initial EDSI ≥1.5 were both associated with low fibrinogen levels.

Background: Whole blood reduces mortality more effectively than blood component therapy in treating trauma. When cold-stored low-titer Type O whole blood (CS-LTOWB) is not available in austere environments, a walking blood bank (WBB) strategy is employed, with blood drawn from a local, pre-screened donor. Proper blood bag volume is essential for avoiding citrate-related complications; however, the optimal method for determining the correct blood bag volume is unclear.

Methods: Novices (n=65) and experts (n=10) at the 1st Marine Division each filled blood bags with the goal of hitting the target volume (450mL ±10%) using the 6.5" beaded cable tie (BC), 10" paracord (PC), and operator gestalt (OG) techniques. Filled bags were weighed on a digital scale. Correct fills, underfills, and overfills were assessed using nonparametric statistics at P=.05. Subjective assessments were also collected.

Results: For novices, OG achieved the highest rate of correct fills (69%), significantly outperforming BC (37%, P=.001) and PC (52%, P=.05). In experts, PC had the highest rate of correct fills (80%), though not significantly different from OG (70%, P=.59) or BC (50%, P=.08). OG was rated highest and was preferred by both groups. BC performed worst in objective and subjective measures for both groups.

Conclusion: BC performed poorly on all assessments and should be avoided. OG was generally superior to BC and PC, but was still suboptimal, with ~30% incorrect fills study-wide. Present findings demonstrate the need for better methods for determining donor blood bag fill volume to preserve the life of the wounded warfighter in WBB scenarios.

The prehospital administration of low-titer O whole blood (LTOWB) has gained attention as a lifesaving intervention in trauma care, demonstrating associated significant survival benefits over traditional crystalloid and component therapies. Despite a growing body of evidence from both military and civilian studies supporting its efficacy, safety, and feasibility, LTOWB continues to face criticism. This article examines commonly raised objections, including concerns over patient identification, blood rewarming, transfusion reactions, and potential risks for childbearing women. Emphasizing the need for transparency and evidence-based progress, this article advocates for the integration of LTOWB into prehospital protocols, positioning it as a crucial advancement in emergency medical services and trauma care.

Introduction: The purpose of this literature review is to identify optimal alternative fresh frozen plasma thawing devices for Austere Resuscitative and Surgical Care (ARSC) teams operating in far forward settings constrained by logistical and operational requirements.

Methods: The authors reviewed existing literature to identify optimal alternative plasma thawing devices and assessed power consumption, weight, durability, portability, post-thaw coagulation preservation, and thaw kinetics. Field-adapted plasma thawers and other commercially available plasma thawing systems were analyzed to determine their suitability to meet the needs of ARSC teams. Sixteen articles were included after evaluating methodological quality and strength of evidence.

Conclusion: The authors recommend that ARSC teams use whole blood, liquid plasma, and FDA-approved thawing devices whenever available. However, if these options are not feasible, alternative methods should be considered to meet mission requirements. Among the devices reviewed, the sous vide demonstrated potential for this application. They are lightweight, compact, versatile, and capable of creating target temperature-controlled circulating water baths, making them superior when compared to other identified field-adapted devices. Dry-based thawing systems, such as the ZipThaw®, may also offer advantages by conserving resources like water and electricity; however, further research is needed to validate its effectiveness in forward operating environments.

Background: We evaluated arterial occlusiveness, 180° turns, pressures, reuse wear, and design aspects of four Ukrainian-manufactured tourniquets.

Methods: Strengthened Individual Combat Hybrid Tourniquets (SICH), TQ DNIPRO GEN 2s (DNIPRO), PULS tourniquets (PULS), and Yellow&Blue tourniquets (Y&B) were each applied to left/right, mid-arm and mid-thigh, of 30 recipients, 100 seconds first-completion-to-release. Results were compared to concurrent study X8T-T2G (n=40).

Results: All applications reached occlusion. Some thigh Y&B could not be secured: 1 never; three after additional turn. Twenty-six arms, 43 thighs needed an additional turn (median total turns arm 1.5 SICH, DNIPRO, PULS; 2.5 Y&B and thigh 2.5 SICH, DNIPRO; 2.0 PULS; 3.5 Y&B; p<.0001 others versus Y&B; X8T-T2G arm 0.7, thigh 1.5, p≤.0004 versus Ukrainian-manufactured). Ukrainian tourniquets pre-release, 39 arm and 83 thigh were >500mmHg (median range: occlusion arm 255-274mmHg, thigh 398-423mmHg; first completion arm 349-588mmHg, thigh 474-572mmHg; pre-release arm 350-638mmHg, thigh 517-583mmHg). No X8T-T2G >500mmHg (median pre-release arm 304mmHg, p<.002 versus SICH, DNIPRO, PULS and p=.522 versus Y&B; thigh 367mmHg, p<.0001 versus Ukrainian-manufactured). For per-turn pressure increases arm>thigh (p<.0001) and additional turns>turns-to-first-completion (p<.0001). Y&B concerns: stitching failures at rod-loop and limb-encircling strap connection; clip bending; potential slider-redirect-buckle-pieces loss, incorrect slider-redirect-buckle rethreading, and windlass-rod removal; and rod-securing inability. On 44.2-75.0cm-circumference thighs, hook-and-loop-strap-base-area-strap-securing mechanisms were not reached on 39% of applications.

Conclusions: The SICH, DNIPRO, and PULS always reached completable arterial occlusion; Y&B did not and had design concerns. None became nonfunctional. Windlass-rod-tightening-system tourniquets routinely have higher-than-desirable completion pressures, which matters with long tourniquet times. Current hook-and-loop-limb-encircling straps are too short to engage base-area-strap-securing mechanisms on many adult thighs.

Background: Trauma in combat or civilian settings often involves severe hemorrhage and open wounds, which carry a high risk of infection. Current clinical guidelines recommend prophylactic antibiotics for high-risk wounds. Adequate plasma antibiotic concentrations are necessary for tissue penetration, particularly into injured tissue. Blood loss from traumatic hemorrhage may impact plasma antibiotic concentrations. However, the association between blood loss, subsequent blood product transfusion, and antibiotic concentrations remains unclear. We hypothesize that antibiotic concentrations decrease in proportion to the volume of blood transfused, potentially leading to insufficient antibiotic concentrations, placing the injured patient at increased infection risk.

Methods: We are conducting a prospective, multicenter study that will enroll trauma patients from two large trauma centers: Brooke Army Medical Center and the University of Colorado Hospital. We will enroll participants receiving antibiotics for wound prophylaxis and three or more units of blood products. We will also enroll a control arm comprised of participants receiving the same antibiotics who receive two or fewer units of blood. Blood samples will be collected from participants at predetermined time intervals after antibiotic infusion to assess antibiotic concentrations. Our statistical analysis will focus on the relationship between the volume of blood products administered and antibiotic concentrations. Results will inform the development of antibiotic dosing models for clinicians that adjust for the effects of blood transfusion.

Conclusion: The goal of this study is to fill a significant gap in trauma care that could potentially lead to optimized antibiotic dosing and improved outcomes for trauma patients.