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

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: 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.

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: The present study examined the effect of a training program with or without equipment on 1000-m surface combat swimming and shooting ability.

Methods: The study included 45 officer cadets who were randomly assigned to one of three groups: a control group (CG), a swimsuit and fins group (SF), and a combat uniform and equipment group (UE). SF and UE followed a 60-min surface combat swimming (sCS) training program for 4 weeks. Before and after the training program, all groups performed a 1000-m sCS trial and shooting in a simulator.

Results: SF and UE improved similarly in 1000-m sCS (134 [SD 115] s, for the SF group and 111 [SD 57] s for the UE group, P<.01). Shooting ability was reduced after the 1000-m sCS, before and after training.

Conclusion: The sCS training had a positive effect on the 1000-m sCS, while did not affect participants shooting ability.

Background: "Non-compressible" torso hemorrhage (NCTH) is the leading cause of preventable battlefield death, requiring rapid surgical or radiological intervention, which is essentially precluded close to the point of injury. UK Joint Theatre Trauma Registry (JTTR) analysis 2002-2012 showed 85.5% NCTH mortality. JTTR vascular injury data 2003-2008 revealed 100% mortality in named truncal vessel injuries. Gas insufflation and hyper-pressure intraperitoneal fluid animal studies have demonstrated significant reductions in blood loss in splanchnic injuries. We hypothesized that the noninvasive Abdominal Aortic Junctional Tourniquet - Stabilized ( AAJT-S) would be a forward combat medic-delivered intervention to tamponade bleeding from vessels of the celiac trunk in descending aorta zone 1 by generating clinically significant proximal epigastric compartment pressure.

Methods: Four cadaveric donors each had two manometric water-filled balloons placed intra-peritoneally (1 epigastric, 1 retropubic), con- nected to manometer tubing. Baseline pressures of 8cmH2O were set (equating mean intra-abdominal pressure (IAP). AAJT-S was applied and inflated to 250mmHg. Pressures were contemporaneously recorded. AAJT-S was removed, along with the epigastric manometer. We added 500mL of water to simulate blood through the epigastric aperture. The manometer was replaced and reset to 8cmH2O. AAJT-S was reapplied to 250mmHg, and IAP steady pressures were again recorded.

Results: Proximal compartment pressures reached a mean of 54.6cmH2O (40.2mmHg); distal compartment pressures achieved a mean of 46cmH2O (34mmHg.) With 500mL intra peritoneal fluid, proximal compartment achieved a mean of 52.25cmH2O (38.4mmHg); distal compartment achieved a mean of 35cmH2O (25.7mmHg.) BMI had a statistically significant inverse effect on epigastric pressure, in this study range (BMIs, 16.7-22.9kg/m2). This proved clinically insignificant, with sufficient pressure still achieved in all tests.

Conclusion: The AAJT-S at 250mmHg achieves proximal epigastric compartment pressures of 40mmHg, with or without 500mL simulated free blood in the abdomen. This represents a highly significant and titratable reduction in blood flow within the celiac trunk branches. BMI does not have a clinically significant effect. AAJT-S application also produces zone 3 aortic and inferior vena cava occlusion. AAJT-S may be a point-of-injury intervention for forward medics that contributes to non-surgical hemorrhage control and likely clot stabilization for zone 1 vascular and solid organ injuries.

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 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.

Background: Junctional hemorrhage is a leading cause of battlefield death. Multiple FDA-approved junctional tourniquet (JTQ) models demonstrate effective hemorrhage control in laboratory settings. However, there are few real-world use cases within the literature.

Methods: We analyzed the Department of Defense Trauma Registry (DoDTR) for casualties with documented JTQ application (2007-2023).

Results: Of 48,301 encounters, 39 included JTQ placement. The most common injury mechanisms were explosives (23), followed by firearms (15). The most common (AIS >3) serious injury sites were the extremities (21), followed by the abdomen (4) and skin (4). Only one patient died. Of nine prehospital interventions, the most common were warming (21), limb tourniquet application (16), and intravenous fluid administration (11). The most common associated diagnoses were lower-extremity amputation (24), testis avulsion or amputation (11), pelvic fracture (9), and tympanic membrane rupture (9). The most common hospital procedures were a focused assessment with sonography in trauma (32), laparotomy (20), chest tube placement (13), fasciotomy (13), and arterial line placement (13).

Conclusion: JTQ application in the combat setting was rare. When it was performed, it was frequently in the polytrauma setting. Survival was high but DoDTR enrollment survival biases likely confounded this.

Background: Research indicates that number of nurse practitioners (NPs) is growing. Additional training is necessary to increase self-efficacy in tactical settings. Evidence shows the Tactical Combat Casualty Care (TC3) course is the national standard for tactical medical training.

Purpose: This pilot study aimed to demonstrate that the TC3 course increases the tactical self-efficacy of flight nurse practitioners (FNPs) in preparation for the role of the law enforcement tactical nurse practitioner.

Methodology: Selected FNPs completed a TC3 course to increase tactical self-efficacy through a combination of formal (didactic), informal (vicarious), and physiological conditioning (scenario-based) positive verbal or written reinforcement, as theorized by Bandura. A general self-efficacy scale (GSES) was administered, and data were compared and analyzed us- ing two-tailed paired t tests.

Results: Clinical relevance was identified in the fact that tactical self-efficacy increased in all participants, and a statistically significant increase in tactical self-efficacy was seen in 50% of the FNPs.

Conclusions: Increasing the tactical self-efficacy of FNPs helped prepare them for the role of the law enforcement tactical nurse practitioner in support of a metropolitan Special Weapons and Tactics team. This project is not generalizable but brings the current body of knowledge together regarding NPs working in tactical environments. Future studies are still needed.