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Importance: Prehospital blood product transfusion in trauma care remains controversial due to poor-quality evidence and cost. Sequential expansion of blood transfusion capability after 2012 to deployed military medical evacuation (MEDEVAC) units enabled a concurrent cohort study to focus on the timing as well as the location of the initial transfusion.Objective: To examine the association of prehospital transfusion and time to initial transfusion with injury survival.Design, Setting, and Participants: Retrospective cohort study of US military combat casualties in Afghanistan between April 1, 2012, and August 7, 2015. Eligible patients were rescued alive by MEDEVAC from point of injury with either (1) a traumatic limb amputation at or above the knee or elbow or (2) shock defined as a systolic blood pressure of less than 90 mm Hg or a heart rate greater than 120 beats per minute.Exposures: Initiation of prehospital transfusion and time from MEDEVAC rescue to first transfusion, regardless of location (ie, prior to or during hospitalization). Transfusion recipients were compared with nonrecipients (unexposed) for whom transfusion was delayed or not given.Main Outcomes and Measures: Mortality at 24 hours and 30 days after MEDEVAC rescue were coprimary outcomes. To balance injury severity, nonrecipients of prehospital transfusion were frequency matched to recipients by mechanism of injury, prehospital shock, severity of limb amputation, head injury, and torso hemorrhage. Cox regression was stratified by matched groups and also adjusted for age, injury year, transport team, tourniquet use, and time to MEDEVAC rescue.Results: Of 502 patients (median age, 25 years [interquartile range, 22 to 29 years]; 98% male), 3 of 55 prehospital transfusion recipients (5%) and 85 of 447 nonrecipients (19%) died within 24 hours of MEDEVAC rescue (between-group difference, -14% [95% CI, -21% to -6%]; P = .01). By day 30, 6 recipients (11%) and 102 nonrecipients (23%) died (between-group difference, -12% [95% CI, -21% to -2%]; P = .04). For the 386 patients without missing covariate data among the 400 patients within the matched groups, the adjusted hazard ratio for mortality associated with prehospital transfusion was 0.26 (95% CI, 0.08 to 0.84, P = .02) over 24 hours (3 deaths among 54 recipients vs 67 deaths among 332 matched nonrecipients) and 0.39 (95% CI, 0.16 to 0.92, P = .03) over 30 days (6 vs 76 deaths, respectively). Time to initial transfusion, regardless of location (prehospital or during hospitalization), was associated with reduced 24-hour mortality only up to 15 minutes after MEDEVAC rescue (median, 36 minutes after injury; adjusted hazard ratio, 0.17 [95% CI, 0.04 to 0.73], P = .02; there were 2 deaths among 62 recipients vs 68 deaths among 324 delayed transfusion recipients or nonrecipients).Conclusions and Relevance: Among medically evacuated US military combat causalities in Afghanistan, blood product transfusion prehospital or within minutes of injury was associated with greater 24-hour and 30-day survival than delayed transfusion or no transfusion. The findings support prehospital transfusion in this setting. [ABSTRACT FROM AUTHOR]

Objectives: Military personnel risk injury due to accidents, disasters, and military threats during Phase Zero "shaping" operations. Medical facilities must be poised to respond.Methods: The U.S. Pacific Command (PACOM) Area of Responsibility (AOR) covers more than 50% of the earth's surface; relevant Clinical Practice Guidelines must include the maritime setting and extended evacuation periods. Military hospitals in the region are not connected by a defined Trauma System. There is variable adherence to trauma training requirements before assignment in this AOR. Demand for trauma care at any 1 location is low and trauma teams have little opportunity to maintain competency for high-risk/low-volume interventions. There is no documentation of total demand for trauma care in the AOR. Trauma care in PACOM is often deferred to civilian facilities.Results: Core elements of a Joint Theater Trauma System (JTTS) as established during combat operations in U.S. Central Command are applicable during Phase Zero. A PACOM JTTS was established to address the region's readiness to respond to Phase Zero trauma as well as escalation of regional threats. Information technology coordination was a critical hurdle to overcome.Conclusion: PACOM lessons learned are applicable to other Geographic Combatant Commands developing a JTTS during Phase Zero operations. [ABSTRACT FROM AUTHOR]

Despite its near-universal use, few data exist to support the efficacy of prehospital supplemental oxygen (PH O2) in trauma patients. Data were reviewed from 5,090 patients not requiring assisted ventilation who were transported to our level I trauma center. Of these, 2,203 (43.3%) received PH O2 and 2,887 (56.7%) did not. Patients who received PH O2 had higher mortality than those without PH O2 (2.3% vs. 1.1%, p = 0.011). When corrected for Injury Severity Score, mechanism of injury, and age, those receiving PH O2 fared worse or no better than those who did not receive it. This suggests that supplemental oxygen does not improve survival in traumatized patients who are not in respiratory distress. This has implications for the management of casualties in combat or austere environments. [ABSTRACT FROM AUTHOR]

: BackgroundSurvival for trauma patients who receive prehospital cardiopulmonary resuscitation (CPR) has been reported as poor. We assessed the survival for prehospital CPR in our trauma system and attempted to find prehospital predictors of mortality.: Study designWe conducted a retrospective review of our Level I trauma center''s database that identified 588 patients over a 6-year period (January 1, 1997, to December 31, 2002) who received prehospital CPR. Mechanisms of injury, prehospital vital signs, and survival to discharge were analyzed.: ResultsTwenty-two of 588 patients (3.7%) survived to hospital discharge. Overall, 60.7% did not survive to achieve hospital admission, and an additional 32.6% died on the first hospital day. Patients with penetrating injuries had a significantly lower survival rate than those with either blunt or other (eg, drowning, hanging) injuries (0.9% versus 6.2%, and 13.2%, respectively, p < 0.001) and significantly lower Revised Trauma Scores (RTS; mean ± SD: 0.32 ± 0.96 versus 0.76 ± 1.84 and 1.18 ± 2.51, respectively, p < 0.05.) The likelihood of survival with RTS = 0 was less than 1% overall, and 0% for penetrating trauma.: ConclusionsThese findings add support to recent guidelines regarding the termination or withholding of resuscitation for trauma patients in the prehospital setting. Victims of penetrating trauma with a prehospital RTS = 0 (combination of no respiratory rate, no systolic blood pressure, and a Glasgow Coma Score of 3) should be declared “dead at the scene.” [Copyright &y& Elsevier]

The article focuses on the need for research funding for the Military Working Dogs (MWD) who save lives on the battlefield. Topics discussed include lack of funds from the Medical Research and Materiel Command (MRMC) Combat Casualty Care Research Program (CCCRP), responsible for mitigating gunshot wounds and explosions, and need for veterinary care of the wounded military dogs.

Critically injured trauma patients benefit from timely transport and care. Accordingly, the provision of rapid transport and effective treatment capabilities in appropriately close proximity to the point of injury will optimize time and survival. Pre-transport tactical combat casualty care, rapid transport with en route casualty care, and advanced damage control resuscitation and surgery delivered early by small, mobile, forward-positioned Role 2 medical treatment facilities have potential to reduce morbidity and mortality from trauma. This retrospective review and descriptive analysis of trauma patients transported from Role 1 entities to Role 2 facilities in Afghanistan from 2008 to 2014 found casualties to be diverse in affiliation and delivered by various types and modes of transport. Air medical evacuation provided transport for most patients, while the shortest transport time was seen with air casualty evacuation. Although relatively little data were collected for air casualty evacuation, this rapid mode of transport remains an operationally important method of transport on the battlefield. For prehospital care provided before and during transport, continued leadership and training emphasis should be placed on the administration and documentation of tactical combat casualty care as delivered by both medical and non-medical first responders. [ABSTRACT FROM AUTHOR]

While combat-related pelvis fractures are more commonly open, higher energy, and complex in pattern than those seen in the civilian setting, the principles of management are similar. The primary differences are related to the austere setting in which the initial management takes place, and the lack of resources typically available. Initial management consists of cessation of hemorrhage, along with the multi-disciplinary prioritized management of associated injuries, and skeletal stabilization. This is most commonly achieved with a compressive sheet or pelvic binder, with pelvic external fixation when resources allow, and debridement of open wounds as necessary. Definitive, internal fixation is delayed until the patient arrives at a higher echelon of care. [ABSTRACT FROM AUTHOR]