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

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an endovascular technology indi-cated for temporarily controlling traumatic life-threatening, noncompressible abdominal, truncal, or pelvic hemorrhage. Through percutaneous access or cut-down to the femoral artery, an intra-aortic balloon catheter is fed into the aorta and inflated, occluding distal blood flow and, thus, bleeding. To determine specific barriers to REBOA in deployed environments, we conducted a quality improvement project and survey of ER-REBOA® placement and monitoring capabilities at four medical treatment locations in Iraq and Kuwait during the spring of 2019.

Methods: The primary objective was to evaluate each in-theater medical site's ability to deploy REBOA, which was defined as having a provider capable of placing REBOA and the minimum equipment necessary. The investigators interviewed providers and through self-reported surveys, determined the personnel capable of placing a REBOA. REBOA equipment and monitoring equipment were identified through direct inspection of sites and interviews with logistical and equipment staff.

Results: A total of 113 individuals participated in the evaluation and training. Three of the four sites had the minimum training and equipment requirements to complete the procedure: one REBOA-capable provider, an unexpired ER-REBOA® device, and an unexpired introducer catheter kit. Overall, 6 out of 32 physicians (18.7%) were capable of placing an ER-REBOA.

Conclusion: This deployed site survey demonstrates that the minimal requirements and personnel for ER-REBOA placement were met at most studied locations in 2019. However, improvements in pre-deployment training of select medical personnel in REBOA and arterial blood pressure monitoring are recommended to ensure adequate resourcing and redundancy in training.

Background: Current triage practices in military mass casualty (MASCAL) events are frequently misaligned with real-world operational needs, leading to delays, confusion, and suboptimal outcomes. Despite the existence of formal triage systems, field responders often default to simplified methods that emphasize speed, clarity, and survivability. This review supports the Committee on Tactical Combat Casualty Care (CoTCCC) recommended transition to a principles-based, two-pass triage system optimized for Role 1 prehospital environments.

Methods: A multi-modal analysis incorporating retrospective case reviews, field surveys, and doctrinal review was conducted to evaluate real-world triage practices across recent military MASCAL incidents. Findings were synthesized to develop an updated triage methodology anchored in clinical judgment, tactical relevance, and operational simplicity.

Results: In 93% of reviewed MASCAL cases, formal triage tools involving color-coded tags and five-category algorithms were not used. Responders preferred a binary or simplified categorization (e.g., urgent vs. nonurgent) for rapid decision-making. The proposed two-pass system includes an initial "first pass" to identify casualties requiring immediate life-saving intervention and a more deliberate "second pass" to sort casualties into urgent, priority, or routine categories aligned with established evacuation precedence. This model emphasizes rapid assessment via the Massive Hemorrhage, Airway, Respirations, Circulation, Hypothermia/Head Injury (MARCH) framework, clear communication between medical and nonmedical personnel, and dynamic re-evaluation as conditions evolve.

Conclusion: The principles-based two-pass triage model offers a practical and operationally aligned framework for Role 1 casualty care. It improves decision-making, communication, and casualty flow during complex MASCAL events while enhancing training, interoperability, and mission success. This approach is endorsed by CoTCCC and integrated into the 2025 TCCC guidelines to optimize outcomes across the full spectrum of military operations.

Introduction: Severe hemorrhage, notably non-compressible torso hemorrhage (NCTH) leading to hemorrhagic shock and traumatic cardiac arrest (TCA), represents a critical and challenging condition in trauma resuscitation. Despite advancements in hemorrhage control for extremities, NCTH continues to present a significant barrier to survival, particularly in the prehospital setting. The abdominal aortic and junctional tour-niquet (AAJT), an external hemorrhage control device, has emerged as a promising tool for addressing junctional and abdominal hemorrhages, yet its clinical effectiveness remains inadequately explored. This review assesses the efficacy of the AAJT in improving survival rates in patients with hemorrhagic shock.

Methods: A systematic literature search was conducted per PRISMA guidelines. Only English-language publications published between 2019 and 2024 were included.

Results: Of the nine relevant publications identified, one was a descriptive case series, seven were animal model studies, and one examined the practicality of the AAJT when tested by combat medic technicians.

Conclusions: The sparse literature did not permit a proper systematic analysis or conclusions on the clinical effectiveness of AAJT in human patients. The AAJT remains a forward-thinking and viable option for improving trauma resuscitation protocols. Further studies, particularly randomized and controlled clinical trials, are required to advance this research.

Background: Heat loss through intravenous (IV) tubing during a fresh whole blood (FWB) transfusion in austere environments can result in unhealthy fluid administration temperatures for patients. This research study aimed to quantify the amount of heat loss through the IV tubing during austere blood transfusions and propose mitigation methods, such as utilizing thermal insulation around the IV tubing and reducing the overall length of the tubing.

Methods: Experiments were conducted in an environmental chamber where fluid temperature was controlled at the inlet of the IV tubing, while the resulting outlet fluid temperatures and volumetric flow rates were measured. The temperature within the environmental chamber was systematically reduced by 3°C from the first collection starting at 20°C to a final collection at -39°C.

Results: Heat loss analysis revealed that 40.9 (SD 3.4) W of heat was lost, even when the ambient temperature was 20 °C. As the environmental temperature reached -39°C, the heat loss through the IV tubing increased to 168 (SD 17.4) W.

Conclusion: Significant heat loss occurs through IV tubing during blood transfusions in cold austere environments. Mathematical models suggest that thermal insulation around the IV tubing and reducing overall tubing length could effectively mitigate these losses.

Background: We hypothesized shared-design tourniquet features have useful first-use learning when knowledge-of-results occurs.

Methods: In a prior study, after watching training videos, 64 volunteers were videoed applying (Latin squares randomization): Combat Application Tourniquet Generation 7 ™ (CAT7), SOF ™ Tactical Tourniquet-Wide Generation 3 (SOFTTW3), SOF™ Tactical Tourniquet-Wide Generation 5 (SOFTTW5), Tactical Mechanical Tourniquet® (TMT), OMNA Marine Tourniquet™ (OMT), X8T-Tourniquet (X8T), Tactical Ratcheting Medical Tourniquet™ (Tac RMT), and RapidStop® Tourniquet (RST). Tourniquets were applied to live thighs with audible distal Doppler pulses.

Results: This study subset was 10 experienced and 33 no-experience appliers. Experienced appliers had fewer strap/redirect and fewer tightening-system understanding problems and faster associated times than no-experience appliers. Among no-experience appliers, firstuse learning was supported by faster "Go" to "strap secured" times for combined seventh and eighth versus first applications (p=.008), secondversus first-encounter CAT7/OMT applications (p=.0005), and secondversus first-encounter SOFTTW3/ SOFTTW5 applications (p=.079). Occlusion at "Done" was more frequent with experienced appliers (p=.006) and did not show first-use learning across all tourniquets in no-experience appliers. Occlusion at "Done" indicated possible first-use learning with ratcheting-buckle versus windlass-rod tightening systems (p=.028, no-experience appliers). Hook-and-loop strap security, which provides no inherent knowledge-of-results, showed no learning in experienced (five problem applications by two appliers) or no-experience appliers (29 problem applications by 18 appliers).

Conclusions: Knowledge-of-results is critical for, but does not guarantee, tourniquet-application-useful first-use learning. The existence of first-use learning can allow limited experience with one tourniquet to improve performance with a different tourniquet with shared-design features. Therefore, exposure to different designs may have value, and providing tourniquet-training knowledge-of-results is important.

Introduction: The Department of Defense has continually refined body armor to mitigate battlefield injuries over the last 20 years. Penetrating axilla injuries remain challenging despite adoption of a four-plate ceramic armor system. This study investigates the efficacy of current armor configurations in reducing mortality and morbidity associated with axilla injuries.

Methods: This was a retrospective case series using afteraction reports from a single Special Operations unit. Records (786) from 2001-2018 were screened, yielding 11 meeting inclusion criteria. Data included injuries, body armor type, clinical interventions, and outcomes.

Results: Analysis revealed significant mortality (45%) among casualties sustaining axilla injuries, with 100% mortality for those struck in uncovered side-plate regions under a two-plate system. In contrast, no fatalities occurred when injuries were within protected side-plate regions of a four-plate system. Injury patterns showed consistent thoracic cavity violations, emphasizing the need for robust protection strategies. This study underscores the efficacy of four-plate systems in reducing mortality compared to older configurations, particularly in protecting vital structures like great vessels and the heart. However, limitations in current side-plate coverage suggest potential gaps in protection, especially superiorly. Balancing protection with mobility remains crucial, as highlighted by operational challenges and weight concerns.

Conclusion: Findings support the role of side plates in mitigating axilla injuries but highlight the need for expanded coverage using improved material technologies. Fu-ture research should focus on enhancing ballistic protection without compromising operational agility and refining trauma management protocols for optimal casualty outcomes.

This case study evaluates a simple, reliable technique for preserving a unit of blood in the field. During a search and rescue exercise in mountainous terrain, a unit of blood was drawn and stored in the rescuer's chest pocket for 13 hours while engaging in rigorous training. Despite temperatures as low as 4°C (40°F), the blood remained liquid and appeared visually viable, suggesting that body heat may help maintain adequate storage temperature. This method offers a low-resource alter-native to expensive or logistically complex storage solutions. A review of historical and modern literature supports the potential effectiveness of this approach, though the absence of laboratory analysis limits definitive conclusions. Given its practicality and historical precedent, this approach warrants further research on biochemical integrity and long-term feasibility to assess its viability for emergency transfusions in combat and wilderness rescue settings.

Introduction: The French Air and Space Force conducts search and rescue (SAR) missions across France. Given the large network of prehospital helicopter services, questions have been raised regarding their national-level efficiency. This study determined how many lives were saved through SAR missions at seven French bases over 5 years.

Methods: We analyzed completed mission reports from seven metropolitan bases between 2015 and 2019. The primary endpoint was the proportion of patients considered to be in imminent danger when the SAR team arrived. Missing person missions were excluded if patients were not located (n=4). We created a composite criterion based on the patient's clinical state or their clinical classification in mobile emergency and resuscitation structures (CCMS). Secondary endpoints included response time and the most frequent mission triggers and medical procedures performed.

Results: Of 175 mission reports, 61 patients (34.9%) were considered to be in imminent danger, and imminent danger could not be determined for 21 (12%). Trauma, secondary transport, neurological distress, and cardiac distress combined accounted for 62% of all cases. The leading causes for mission deployment were traumatic pathologies (18.9%), secondary transfers (16%), and neurological distress (14.3%). The most common procedures were volume expansion (77 times), morphine administration (33), and oxygen therapy (30).

Conclusion: SAR missions primarily assist seriously ill or injured patients in isolated areas where traditional emergency services are limited. They are often deployed as a last resort. They regularly fill a capacity deficit where conventional rescuers cannot operate and contribute to improving the prognosis of rescued patients.

The Joint Trauma System Clinical Practice Guideline on Traumatic Brain Injury Management in Prolonged Field Care recommends the use of ultrasound measurement of optic nerve sheath diameter (ONSD) in the neurologic assessment of unconscious patients without ocular injury. This recommendation is well-founded in the literature, and support is growing for use of ONSD measurement for monitoring of neurocritical patients, especially in resource-limited and austere environments, including military theaters of operation. Our patient presented as a level 1 trauma patient with a penetrating traumatic brain injury (TBI). ONSD measurements taken before, during, and after administration of a 250mL bolus of 3% hypertonic saline showed a downward trend in ONSD measurement, from 5.4 to 4.8mm in the right eye, and 7.6 to 6.3mm in the left eye, within 20 minutes. Our review of the literature identified studies in which ONSD decreased following treatment of symptomatic hyponatremia with 3% hypertonic saline, as well as cases in which ONSD decreased in real time following lumbar puncture and external ventricular drain placement. Many studies also demonstrate the usefulness of ONSD for screening and monitoring of patients with TBI. Ours is the first reported instance of which we are aware showing real-time reduction in ONSD following treatment with 3% hypertonic saline in a patient with a penetrating TBI. ONSD measurement has potential for neurocritical monitoring in austere, resource-limited environments, including prolonged field care. Further study is needed to interrogate the accuracy and reliability of ONSD measurement as a tool for assessing treatment efficacy in patients with TBI, both blunt and penetrating.