Medical journal (Fort Sam Houston, Tex.)最新文献

Introduction: Limited literature exists examining outcomes associated with alternative thresholds for massive transfusion outside of the historical definition of 10 units of packed red blood cells (PRBC) in 24 hours. This study reports the predictive accuracy of alternative thresholds for 24-hour mortality and explores implications for Role 1 care supply requirements.

Methods: We conducted a secondary analysis of data from the Department of Defense Trauma Registry (DODTR) spanning encounters from 1 January 2007 through 17 March 2020. We included all casualties who received at least 1 unit of either PRBC or whole blood. We calculated area under the receiver operator curve (AUROC) of blood product quantity received, including both PRBC and whole blood, as a predictor for mortality within 24 hours of arrival to a military treatment facility. We identified optimal predictive thresholds per Youden's index.

Results: We identified 28,950 encounters of which 2,608 (9.0%) entailed receipt of at least 1 unit of PRBC or whole blood. Most casualties sustained battle injuries (2,437, 93.4%) with explosives as the most common mechanism (1,900, 72.8%) followed by firearms (609, 23.3%). The AUROC for blood product received within 24 hours was 0.59. The optimal threshold for predicting 24-hour mortality per Youden's Index was 20 units (sensitivity of 34.9% and specificity of 78.6%). The threshold exceeding 90% sensitivity was 2 units; whereas, the threshold exceeding 90% specificity was 33 units.

Conclusions: We identified a wide range of numbers of received blood products associated with short-term mortality based upon prioritization of sensitivity or specificity. This study found only 2 units of blood product received had a 90% sensitivity for predicting 24-hour mortality, highlighting the resource mobilization challenges that confront healthcare providers during resuscitation at the Role 1.

Background: Traumatic brain injury (TBI) affects civilian and military populations with high morbidity and mortality rates and devastating sequelae. As the US military shifts its operational paradigm to prepare for future large-scale combat operations, the need for prolonged casualty care is expected to intensify. Identifying efficacious prehospital TBI management strategies is therefore vital. Numerous pharmacotherapies are beneficial in the inpatient management of TBI, including beta blockers, calcium channel blockers, statins, and other agents. However, their utility in prehospital management of moderate or severe TBI is not well understood. We performed a systematic review to elucidate agents of potential prehospital benefit in moderate and severe TBI.

Methods: We searched 6 databases from January 2000 through December 2021 without limitations in outcome metrics using a variety of search terms designed to encapsulate all studies pertaining to prehospital TBI management. We identified 2,142 unique articles, which netted 114 studies for full review. Seven studies met stringent inclusion criteria for our aims.

Results: Studies meeting inclusion criteria assessed tranexamic acid (TXA) (n=6) and ethanol (n=1). Of the TXA studies, 3 were randomized controlled trials, 2 were retrospective cohort studies, 1 was a prospective cohort study, and 1 was a meta-analysis. Notably absent were papers investigating therapeutics shown to be beneficial in inpatient hospital treatment of TBI. Overall, data suggest TXA administration is potentially beneficial in moderate or severe TBI with or without intracranial hemorrhage. Severe TBI with or without penetrating trauma was associated with worse overall outcomes, regardless of TXA use.

Conclusion: Effective interventions for treating moderate or severe TBI are lacking. TXA is the most widely studied pharmacologic intervention and appears to offer some benefit without adverse effects in moderate TBI (with or without intracranial hemorrhage) in the pre-hospital setting despite heterogeneous results. Limitations of these studies include heterogeneity in outcome metrics, patient populations, and circumstances of TXA use. We identified a gap in the literature in translating agents with demonstrated inpatient benefit to the prehospital setting. Further investigation into these and other novel therapeutic options in the prehospital arena is crucial to improving clinical outcomes in TBI.

Background: Correct identification and rapid intervention of a traumatic pneumothorax is necessary to avoid hemodynamic collapse and subsequent morbidity and mortality. The purpose of this clinical review is to summarize the evaluation and best treatment strategies to improve outcomes in combat casualties. Blunt, explosive, and penetrating trauma are the 3 etiologies for causing a traumatic pneumothorax. Blunt trauma tends to be more common, but all etiologies require similar treatment. The current standard to diagnose pneumothorax is through imaging to include ultrasound, chest x-ray, or computed tomography. A physical exam aids in the diagnosis especially when few other resources are available. Recent studies on the treatment of a small, closed pneumothorax involve conservative care, which includes close observation of the patient and monitoring supplemental oxygen. For a large, closed pneumothorax, conservative treatment is still a possible option, but manual aspiration may be required. Less often, a needle or tube thoracostomy is needed to reinflate the lung. Large, open pneumothoraxes require the most invasive treatment with current guidelines recommending tube thoracostomy. More invasive management options can result in higher rates of complications. Given the significant variability in practice patterns, most notable in resource limited settings, the areas for potential research are presented.

Large-scale combat and multi-domain operations will pose unprecedented challenges to the military healthcare system. This scoping review examines the specific challenges related to the management of airway compromise, the second leading cause of potentially preventable death on the battlefield. Closing existing capability gaps will require a comprehensive approach across all components of the Joint Capabilities Integration Development System. In this, we present the case for a change in doctrine to selectively provide definitive airway management in prehospital settings to maximize the effectiveness of limited resources. Organizational changes to optimize training and efficiency in delivery of complex airway intervention include centralization of assigned healthcare personnel. Training must vastly increase opportunities for live tissue and patient experiences to obtain repetitions of both non-invasive and definitive airway procedures. Potential materiel solutions include extra-glottic devices, bag-valve masks, video laryngoscopes, and oxygen generators all ruggedized and capable of operations in austere settings. Leadership and education changes must formalize more robust airway skills into the initial training curricula for more healthcare personnel who will potentially need to perform these life-saving interventions. Simultaneously, personnel changes should expand authorizations for clinicians with advanced airway skills to the lowest echelons of care. Finally, existing medical training and treatment facilities must expand as necessary to accommodate the training and skill maintenance of these personnel.

Background: Airway obstruction is the second leading cause of potentially survivable death on the battlefield. Previous studies demonstrate casualties undergoing airway interventions have worse outcomes when the procedure occurs in the prehospital setting versus the military treatment facility (MTF) setting. We compare outcomes between casualties undergoing airway management in these 2 settings using the Department of Defense Trauma Registry (DODTR).

Methods: This is a secondary analysis of a previously described dataset from the DODTR. We included US military casualties with at least 24 hours on the ventilator. We compared casualties who underwent intubation in the prehospital setting versus hospital setting. Multivariable logistic regression models were constructed to adjust for available confounders.

Results: There were 2,124 that met inclusion for this analysis-278 in the prehospital cohort and 1,846 in the MTF cohort. Median injury severity scores were higher in the prehospital cohort (25 versus 22, p is less than 0.001). The survival to discharge was lower in the prehospital cohort (80% versus 93%, p is less than 0.001). On multivariable logistic regression model, when adjusting for injury severity score, mechanism of injury, and first 24-hour blood products, the odds of survival were 0.34 (95% CI 0.23-0.50) for those intubated prehospital versus MTF.

Conclusions: We found worse survival for those with prehospital airway intervention versus those in the MTFsetting. These findings persisted after adjustment for measurable confounders. Our findings suggest prehospital-focused improvements in airway interventions are needed and/or robust methods for rapid evacuation to an MTF for airway intervention.

Introduction: The US military is transitioning into a posture preparing for large-scale combat operations in which delays in evacuation may become common. It remains unclear which casualty population can have their initial surgical interventions delayed, thus reducing the evacuation demands.

Methods: We performed a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry (DODTR) focused on casualties who received prehospital care. In this, we sought to determine (1) of those who underwent operative intervention, the proportion of surgeries occurring ≥3 days post-injury, and (2) of those who underwent early versus delayed surgery, the proportions who required blood products.

Results: There were 6,558 US military casualties who underwent surgical intervention-6,224 early (less than 3 days from injury) and 333 delayed (≥ 3 days from injury). The median Injury Severity Score (ISS) was higher in the early cohort (10 versus 6, p is less than 0.001). Serious injuries to the head were more common in the early cohort (12% versus 5%, p is less than 0.001), as were the thorax (13% versus 9%, p=0.041), abdomen (10% versus 5%, p=0.001), extremities (37% versus 14%, p is less than 0.001), and skin (4% versus less than 1%, p=0.001). Survival to discharge was lower in the early cohort (97% versus 100%, p is less than 0.001). Mean whole blood consumption was higher in the early cohort (0.5 versus 0 units, p is less than 0.001), as was packed red blood cells (6.3 versus 0.5, p is less than 0.001), platelets (0.9 versus 0, p is less than 0.001), and fresh frozen plasma (4.5 versus 0.2, p is less than 0.001). The administration of any units of packed red blood cells and whole blood was higher for the early cohort (37% versus 7%, p is less than 0.001), as was a ≥3 units threshold (30% versus 3%, p is less than 0.001), and ≥10 units threshold (18% versus 1%, p is less than 0.001).

Conclusions: Few combat casualties underwent delayed surgical interventions defined as ≥3 days post injury, and only a small number of casualties with delayed surgical intervention received blood products. Casualties who received early surgical intervention were more likely to have higher injury severity scores, and more likely to receive blood.

Introduction: Airway obstruction is the second leading cause of potentially survivable death on the battlefield. The Committee on Tactical Combat Casualty Care (CoTCCC) has evolving recommendations for the optimal supraglottic airway (SGA) device for inclusion to the medics' aid bag.

Methods: We convened an expert consensus panel consisting of a mix of 8 prehospital specialists, emergency medicine experts, and experienced combat medics, with the intent to offer recommendations for optimal SGA selection. Prior to meeting, we independently reviewed previously published studies conducted by our study team, conducted a virtual meeting, and summarized the findings to the panel. The studies included an analysis of end-user after action reviews, a market analysis, engineering testing, and prospective feedback from combat medics. The panel members then made recommendations regarding their top 3 choices of devices including the options of military custom design. Simple descriptive statistics were used to analyze panel recommendations.

Results: The preponderance (7/8, 88%) of panel members recommended the gel-cuffed SGA, followed by the self-inflating-cuff SGA (5/8, 62%) and laryngeal tube SGA (5/8, 62%). Panel members expressed concerns primarily related to the (1) devices' tolerance for the military environment, and (2) ability to effectively secure the gel-cuffed SGA and the self-inflating-cuff SGA during transport.

Conclusions: A preponderance of panel members selected the gel-cuff SGA with substantial feedback highlighting the need for military-specific customizations to support the combat environment needs.

Background: Over the course of the US' Global War on Terrorism, its military has utilized both conventional and special operations forces (SOF). These entities have sustained and treated battlefield casualties in the prehospital, Role 1 setting, while also making efforts to mitigate risks to the force and pursuing improved interventions. The goal of this study is to compare outcomes and prehospital medical interventions between SOF and conventional military combat casualties.

Methods: This is a secondary analysis of previously published data from the Department of Defense Trauma Registry. The casualties were categorized as special operations if they were 18-series, Navy SEAL, Pararescue Jumper, Tactical Air Control Party, Combat Controller, and Marine Corps Force Reconnaissance. The remainder with a documented military occupational specialty (MOS) were classified as conventional forces.

Results: Within our dataset, a MOS was categorizable for 1806 conventional and 130 special operations. Conventional forces were younger age (24 versus 30, p is less than 0.001). Conventional forces had a higher proportion of explosive injuries (61% versus 44%) but a lower proportion of firearm injuries (22% versus 42%, p is less than 0.001). The median injury severity scores were similar between the groups. Conventional forces had lower rates of documentation for all metrics: pulse, respiratory rate, blood pressure, oxygen saturation, Glasgow Coma Scale, and pain score. On adjusted analyses, SOF had higher odds of receiving an extremity splint, packed red blood cells, whole blood, tranexamic acid, ketamine, and fentanyl.

Conclusion: SOF had consistently better medical documentation rates, more use of ketamine and fentanyl, less morphine administration, and lower threshold for use of blood products in both unadjusted and adjusted analyses. Our findings suggest lessons learned from the SOF medics should be extrapolated to the conventional forces for improved medical care.

Background: Over the course of the US' Global War on Terrorism, its military has utilized both conventional and special operations forces (SOF). These entities have sustained and treated battlefield casualties in the prehospital, Role 1 setting, while also making efforts to mitigate risks to the force and pursuing improved interventions. The goal of this study is to compare outcomes and prehospital medical interventions between SOF and conventional military combat casualties.

Methods: This is a secondary analysis of previously published data from the Department of Defense Trauma Registry. The casualties were categorized as special operations if they were 18-series, Navy SEAL, Pararescue Jumper, Tactical Air Control Party, Combat Controller, and Marine Corps Force Reconnaissance. The remainder with a documented military occupational specialty (MOS) were classified as conventional forces.

Results: Within our dataset, a MOS was categorizable for 1806 conventional and 130 special operations. Conventional forces were younger age (24 versus 30, p is less than 0.001). Conventional forces had a higher proportion of explosive injuries (61% versus 44%) but a lower proportion of firearm injuries (22% versus 42%, p is less than 0.001). The median injury severity scores were similar between the groups. Conventional forces had lower rates of documentation for all metrics: pulse, respiratory rate, blood pressure, oxygen saturation, Glasgow Coma Scale, and pain score. On adjusted analyses, SOF had higher odds of receiving an extremity splint, packed red blood cells, whole blood, tranexamic acid, ketamine, and fentanyl.

Conclusion: SOF had consistently better medical documentation rates, more use of ketamine and fentanyl, less morphine administration, and lower threshold for use of blood products in both unadjusted and adjusted analyses. Our findings suggest lessons learned from the SOF medics should be extrapolated to the conventional forces for improved medical care.

Major trauma frequently occurs in the deployed, combat setting and is especially applicable in the recent conflicts with explosives dominating the combat wounded. In future near-peer conflicts, we will likely face even more profound weapons including mortars and artillery. As such, the number of severely wounded will likely increase. Hypocalcemia frequently occurs after blood transfusions, secondary to the preservatives in the blood products; however, recent data suggests major trauma in and of itself is a risk factor for hypocalcemia. Calcium is a major ion involved in heart contractility; thus, hypocalcemia can lead to poor contractility. Smaller studies have linked hypocalcemia to worse outcomes, but it remains unclear what causes hypocalcemia and if intervening could potentially save lives. The objective of this study is to determine the incidence of hypocalcemia on hospital arrival and the association with survival. We are seeking to address the following scientific questions, (1) Is hypocalcemia present following traumatic injury prior to transfusion during resuscitation? (2) Does hypocalcemia influence the amount of blood products transfused? (3) To what extent is hypocalcemia further exacerbated by transfusion? (4) What is the relationship between hypocalcemia following traumatic injury and mortality? We will conduct a multicenter, prospective, observational study. We will gather ionized calcium levels at 0, 3, 6, 12, 18, and 24 hours as part of scheduled calcium measurements. This will ensure we have accurate data to assess the early and late effects of hypocalcemia throughout the course of resuscitation and hemorrhage control. These data will be captured by a trained study team at every site. Our findings will inform clinical practice guidelines and optimize the care delivered in the combat and civilian trauma setting. We are seeking 391 patients with complete data to meet our a priori inclusion criteria. Our study will have major immediate short-term findings including risk prediction modeling to assess who is at risk for hypocalcemia, data assessing interventions associated with the incidence of hypocalcemia, and outcome data including mortality and its link to early hypocalcemia.