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Background: Femur shaft fractures (FSF) are perceived as potentially life-threatening injuries due to significant blood loss. However, these injuries are rarely the sole cause of hemorrhagic shock. Clinical practice guidelines for the prehospital management of FSF are inconsistent, especially concerning the use and timing of traction splinting which is postulated to reduce bleeding. We sought to understand the association between FSF and shock, and identify risk factors for shock among casualties with FSF., Methods: This is a retrospective analysis of trauma casualties treated by Israeli Defense Forces (IDF) medical teams between the years 2000-2020 and suffering from isolated FSF. Prehospital data from the IDF-Medical Corps Trauma Registry was merged with hospitalization data from the Israeli National Trauma Registry. Isolated FSF was analyzed by excluding casualties with an Injury Severity Score ≥ 16 and an Abbreviated Injury Scale ≥ 3 in other anatomical regions. Shock was defined as systolic blood pressure ≤ 90 mmHg and/or heart rate ≥ 130 beats per minute. A case series review was performed for casualties in shock with isolated FSF injuries. Multivariable logistic regression was performed to assess for injury characteristics associated with shock., Results: During the study period, we identified 213 patients with FSF (4.9%) of which 129 were isolated injuries. Overall, 9.9% and 26.3% of casualties had concurrent thoracic and abdominal injuries, respectively. Most FSF were due to motor vehicle accidents (60.1%) and shock was present in 17.1%. In isolated FSF patients, gunshot and explosive injury mechanisms were prevalent (65.0%) with severe shock being present in 8.5%. Open fractures were present in 72.7% of isolated FSF patients in shock. Open FSF injuries were characterized by prehospital bleeding which was difficult to control. In a multivariable logistic regression model, severe concomitant injuries were associated with increased odds of shock., Conclusions: Shock rarely presents when FSF is the primary injury. Such casualties predominantly suffer from open FSF which may present as difficult to control thigh bleeding. Our findings do not support urgent prehospital leg traction splinting which may result in delayed evacuation to definitive care. Casualties with shock and FSF should be investigated for other sources of bleeding. Leg traction splinting should be reserved for suspected FSF injuries with shock or persistent thigh bleeding., Competing Interests: Declaration of Competing Interest None to declare., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: Freeze dried plasma (FDP) is a commonly used replacement fluid in the prehospital setting when blood products are unavailable. It is normally administered via a peripheral intravenous (PIV) line. However, in severe casualties, when establishing a PIV is difficult, administration via intraosseous vascular access is a practical alternative, particularly under field conditions., Objectives: To evaluate the indications and success rate of intraosseous administration of FDP in casualties treated by the Israel Defense Forces (IDF)., Methods: A retrospective analysis of data from the IDF-Trauma Registry was conducted. It included all casualties treated with FDP via intraosseous from 2013 to 2019 with additional data on the technical aspects of deployment collected from the caregivers of each case., Results: Of 7223 casualties treated during the study period, intravascular access was attempted in 1744; intraosseous in 87 of those. FDP via intraosseous was attempted in 15 (0.86% of all casualties requiring intravascular access). The complication rate was 73% (11/15 of casualties). Complications were more frequent when the event included multiple casualties or when the injury included multiple organs. Of the 11 failed attempts, 5 were reported as due to slow flow of the FDP through the intraosseous apparatus. Complications in the remaining six were associated with deployment of the intraosseous device., Conclusions: Administration of FDP via intraosseous access in the field requires a high skill level.

Background: Hemorrhage is the leading cause of possible preventable death in the battlefield. There is an increasing evidence for the effectiveness of blood component therapy in general, and plasma infusion in particular but their use is less applicable in the prehospital setting due to logistic difficulties. Israeli Defense Force has implemented the use of freeze-dried plasma (FDP) at the point of injury (POI), this adoption of FDP use entailed doubts regarding the feasibility and effectiveness of this practice. In this article, we present our experience with the use of FDP at the POI and prehospital setting regarding the feasibility, safety, adverse reactions, and adherence to clinical practice guidelines., Methods: This is a descriptive retrospective cohort study based on all casualties receiving FDP during January 2013 to June 2016. The study describes the injury, treatment, and outcome characteristics from POI until hospital discharge., Results: During the study period, 109 casualties received FDP. The majority were men, aged 18 years to 35 years. Multiple severe injuries were found in almost half of the casualties, 78% had penetrating injury, and more than half were involved in a multicasualty event. Eighty-three percent were treated with one unit of FDP, 13% with two units, and 4% casualties with three units, nine patients (8.2%) were also treated in the prehospital setting with packed red blood cells. Fifty-seven percent fulfilled at least one criterion for the administration of FDP. Lifesaving interventions were required in 64%. In five (4.6%) cases, there were difficulties with FDP administration. Side effects were reported in one female patient., Conclusion: This study supports the usage feasibility of FDP at the POI and in the prehospital setting. Further adjustment of the clinical practice guidelines is required basing it not only on pathophysiologic parameters but also on clinical judgment. Further investigation of the available data is required to learn about the effectiveness of FDP at POI., Level of Evidence: Retrospective case series study, level IV.

Objective:Tourniquet application is a lifesaving skill taught worldwide in first aid bleeding control courses. We observed performance among non-medical users of tourniquets in their confidence, competence, and reasons for failure.Methods:179 Israeli military recruits without prior medical training underwent their standard first aid course where they learned Combat Application Tourniquet (CAT; Composite Resources, Rock Hill, SC, USA) use. After course completion, they self-reported confidence in tourniquet use. User performance was assessed 7–14 days later using a HapMed™ mannequin that assessed time, pressure, and blood loss. Competent performance required in aggregate: 1) use with pressure of 200 mmHg or more, 2) hemorrhage volume of less than 638 mL, and 3) correct placement of the tourniquet. For failed performance, a reason for failure was reported independently by both the user and an expert observer.Results:45 of 179 user performances (25%) were competent. Users who reported high confidence had only a slightly higher chance of achieving competence in tourniquet application (r = 0.17, p = 0.022). The most common reason for failure was excess slack in the CAT's strap (experts 55%, users 39%), and too few turns of the windlass (23% and 31%, respectively) was the second most common reason. Expert and user evaluations had poor agreement (κ = 0.44, 95% CI 0.32–0.56).Conclusion:The most common reason for failed use of tourniquets among non-medical users was excess slack in the tourniquet strap. Users self-evaluated their performance inaccurately and demonstrated a confidence-competence mismatch. These pitfalls in performance may help tourniquet instructors improve training of caregivers. [ABSTRACT FROM PUBLISHER]