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The MARCH (Massive hemorrhage, Airway, Respirations, Circulation, and Hypothermia/Head injuries) algorithm taught to military medics includes interventions to prevent hypothermia. As possible sequelae from major trauma, hypothermia is associated with coagulopathy and lower survival. This paper sought to define hypothermia within our combat trauma population using an outcomes-based method, and determine clinical variables associated with hypothermia.This is a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry focused on casualties who received prehospital care. A receiver operating curve was constructed and Youden's index was used to define hypothermia within the predetermined population based on mortality risk. A multivariable regression model was used to identify associations.There were 23,243 encounters that met the inclusion criteria for this study with patients having received prehospital care and documentation of at least one emergency department temperature. An optimal threshold of 36.2° C was found to predict mortality; 3,159 casualties had temperatures below this threshold (14%). Survival to discharge was lower among casualties with hypothermia (91% versus 98%). Hypothermic casualties were less likely to undergo blanket application (38% versus 40%). However, they had higher proportions with Hypothermia Prevention and Management Kit application (11% versus 7%) and radiant warming (2% versus 1%). On multivariable regression modeling, none of the hypothermia interventions were associated with a decreased likelihood of hypothermia. Non-hypothermia interventions associated with hypothermia included prehospital intubation (OR 1.57, 95% CI 1.45-1.69) and blood product administration.Hypothermia, including a single recorded low temperature in the patient care record, was associated with worse outcomes in this combat trauma population. Prehospital intubation was most strongly associated with developing hypothermia. Prehospital warming interventions were not associated with a reduction in hypothermia risk. Our dataset suggests that current methods for prehospital warming are inadequate.

Introduction: Patients experiencing traumatic shock are at a higher risk for death and complications. We previously designed a bundle of emergency medical services traumatic shock care (“EMS-TruShoC”) for prehospital providers in resource-limited settings. We assess how EMS-TruShoC changes clinical outcomes of critically injured prehospital patients. Methods: This is a quasi-experimental educational implementation of a simplified bundle of care using a pre-post design with a control group. The intervention was delivered to EMS providers in Western Cape, South Africa. Delta shock index (heart rate divided by systolic blood pressure, reported as change from the scene to facility arrival) from the 13 months preceding intervention were compared to the 13 months post-implementation. A difference-in-differences analysis examined the difference in mean shock index change between the groups. Results: Data were collected from 198 providers who treated 770 severe trauma patients. The patient groups had similar demographic and clinical characteristics at baseline. Over all time-points, both groups had an increase in mean delta shock index (worsening shock), with the largest difference occurring 4-months post-implementation (0.047 change in control arm, 0.004 change in intervention arm; −0.043 difference-in-differences, P = 0.27). In pre-specified subgroup analyses, there was a statistically significant improvement in delta shock index in the intervention arm in patients with penetrating trauma cared for by basic providers immediately post-implementation (−0.372 difference-in-differences, P = 0.02). Discussion: Overall, there was no significant difference in delta shock index between the EMS-TruShoC intervention versus control groups. However, significant improvement in shock index in one subgroup suggests the intervention may be more likely to benefit penetrating trauma patients and basic providers.

IntroductionWith more than 370,000 military and civilian personnel stationed across Pacific Command (PACOM), medical evacuation in this largest command presents unique challenges. The authors describe medical evacuations analyzed from the U.S. Air Force Transportation Command Regulating and Command & Control Evacuation System (TRAC2ES) in PACOM.Materials and MethodsWe performed a retrospective review of all TRAC2ES medical records for medical evacuations of adult patients from the PACOM theater of operations conducted between January 1, 2008 and December 31, 2018. We abstracted free text data entry in TRAC2ES to characterize the diagnoses requiring patient movement. Data are presented using descriptive statistics.ResultsDuring this 11-year period, 3,328 PACOM TRAC2ES encounters met inclusion criteria. Of these evacuations, 65.8% were male and were comprised mostly of active duty military (1,600, 48.1%) and U.S. civilians (1,706, 51.3%). Most transports originated in Japan (1,210 transports, 36.4%) or Guam (924 transports, 27.8%) with Hawaii (1,278 transports, 38.4%) as the most frequent destination. The majority of evacuations were routine (72.5%) with only 4.9% urgent evacuations. Medical conditions (2,905 transports, 87%) accounted for the largest proportion of transports, surpassing injuries (442 transports, 13%). The most common reasons for medical transports were behavioral health (671 transports, 20.2%) and cardiovascular disease (505 transports, 15.1%).ConclusionsThe majority of medical evacuations in PACOM were because of medical illness with routine precedence category, mirroring the largely noncombat operations occurring across this large area.

Extracorporeal membrane oxygenation (ECMO) is an advanced medical technology used to treat respiratory and heart failure. The coronavirus pandemic has resulted in significantly more ECMO patients worldwide. However, the number of hospitals with ECMO capabilities and ECMO-trained staff are limited. Training of personnel in ECMO could supplement this demand.To evaluate our previously developed ECMO course using a task trainer-based training, as opposed to an existing live tissue-training model, and determine if such a program was adequate and could be expanded to other facilities.Seventeen teams, each consisting of a physician and nurse, underwent a 5 hour accelerated ECMO course in which they watched prerecorded ECMO training lectures, primed circuit, cannulated, initiated ECMO, and corrected common complications. Training success was evaluated via knowledge and confidence assessments and observation of each team attempting to initiate ECMO while troubleshooting complications on a Yorkshire swine.Seventeen teams successfully completed the course. Sixteen teams (94%, 95% CI = 71%-100%) successfully placed the swine on veno-arterial ECMO. Of those 16 teams, 15 successfully transitioned to veno-arterial-venous ECMO. The knowledge assessments and confidence levels of physicians and nurses increased by 24.3% from pretest (mean of 65.3%, SD 14.4%) to posttest (mean of 89.6%, SD 10.3%),An abbreviated one day lecture and hands-on task trainer-based ECMO course resulted in a high rate of successful skill demonstration and improvement of physicians' and nurses' knowledge assessments and confidence levels, similar to our previous live tissue training program.

IntroductionUncontrolled hemorrhage remains the leading cause of preventable death in the prehospital, combat setting. Treatment guidelines emphasize immediate hemorrhage control and early resuscitation with whole blood or blood products. Current methods for the delivery of blood products are often insufficient to provide trauma resuscitation. The novel LifeFlow device is a hand-powered device that can rapidly infuse fluids, including blood products. However, successful use of this device in the hands of the intended end user has not been demonstrated.Materials and MethodsWe conducted a pilot study to assess how quickly and effectively medics could set up the LifeFlow device and infuse mock blood products into a casualty. They were provided with a brief block of instruction (ResultsForty medics, who were recruited and eligible to participate, completed the study procedures. All medics were able to successfully set up the device and perform the infusion. We had two instances of fluid leakage owing to malfunctions with the simulation arm, not the LifeFlow device. The mean time to device setup was 112 s (95% confidence interval [CI], 101-124). The mean time for infusion of 500 mL of fluid was 94 s (95% CI, 83-105). The mean time for all procedures was 197 s (95% CI, 178-213). On product feedback, they generally found it easier to use, easy to manipulate, possessing a useful grip, easily set up, and requiring minimal training.ConclusionsThe medics were able to reliably assemble and use the LifeFlow rapid infusion device. However, there were concerns about the packaging and the single indication for the device.

Introduction The US Army Burn Center, the only burn center in the Department of Defense provides comprehensive burn care. The Burn Flight Team (BFT) provides specialized burn care during transcontinental evacuation. During Operations Iraqi and Enduring Freedom, burn injuries accounted for approximately 5% of all injuries in military personnel. To augment BFT capacity, US Air Force Critical Care Air Transport Teams (CCATTs) mobilized to transport burn patients. The purpose of this study was to describe critically ill, burn injured patients transported to the US Army Burn Center by BFT or CCATT, to compare and contrast characteristics, evacuation procedures, in-flight treatments, patient injuries/illnesses, and outcomes between the two groups. Materials and Methods We conducted a retrospective cohort study of CCATT and BFT patients, admitted to the burn ICU between January 1, 2001 and September 30, 2018. Patients with total body surface area burned (TBSA) >30% were evacuated by BFT, while CCATT evacuated patients with ≤ 30% TBSA. Results Ninety-seven patients met inclusion criteria for this study. Of these, 40 (41%) were transported by the BFT and 57 (59%) were transported by CCATTs. Compared with patients transported by CCATTs, patients transferred by the BFT had higher median TBSA and full-thickness burn size, higher prevalence of chest, back and groin burns, and higher prevalence of inhalation injury. BFT patients had increased hospital days (62 vs. 37; P = .08), ICU days (29 vs. 12; P = .003) and ventilator days (14 vs. 6; P Conclusions Evacuation by the BFT was associated with increased ICU and ventilator days, increased mortality, and a greater risk for developing renal failure. The severity of injury/TBSA likely accounted for most of these differences.

Background The U.S. Indo-Pacific Command (INDOPACOM) has over 375,000 military personnel, civilian employees, and their dependents. Routine pediatric care is available in theater, but pediatric subspecialty, surgical, and intensive care often require patient movement. Transfer is frequently performed by military air evacuation teams and intermittently augmented by civilian services. Pediatric care requires special training and equipment, yet most transports are staffed by non-pediatric specialists. We seek to describe the epidemiology of pediatric transport missions in INDOPACOM. Methods A retrospective review of all patients less than 18 years old transported within INDOPACOM and logged into the Transportation Command Regulating and Command and Control Evacuation System (TRAC2ES) database from June 2008 through June 2018 was conducted. Data are reported using descriptive statistics. Patients were categorized into four age groups: neonatal ( Results During the study period, 687 out of 4,217 (16.3%) transports were children. Median age was 4 years (interquartile range 6 months to 8 years) and 654 patients (95.2%) were transported via military fixed-wing aircraft. There were 219 (31.9%) neonates, 162 (23.6%) infants, 133 (19.4%) young children, and 173 (25.2%) older children. Most common diagnoses encountered were respiratory, cardiac, or abdominal, although older children had a higher percentage of psychiatric diagnoses (28%). Mechanical ventilation was used in 118 (17.2%) patients, and 75 (63.6%) of these patients were neonates. Conclusions Within TRAC2ES, nearly one in six encounters were patients aged

A benzo[6]annulene, 4-(tert-butyl)-N-(3-methoxy-5,6,7,8-tetrahydronaphthalen-2-yl) benzamide (1a), was identified as an inhibitor against Chikungunya virus (CHIKV) with antiviral activity EC(90) = 1.45 μM and viral titer reduction (VTR) of 2.5 log at 10 μM with no observed cytotoxicity (CC(50) = 169 μM) in normal human dermal fibroblast cells. Chemistry efforts to improve potency, efficacy, and drug-like properties of 1a resulted in a novel lead compound 8q, which possessed excellent cellular antiviral activity (EC(90) = 270 nM and VTR of 4.5 log at 10 μM) and improved liver microsomal stability. CHIKV resistance to an analog of 1a, compound 1c, tracked to a mutation in the nsP3 macrodomain. Further mechanism of action studies showed compounds working through inhibition of human dihydroorotate dehydrogenase in addition to CHIKV nsP3 macrodomain. Moderate efficacy was observed in an in vivo CHIKV challenge mouse model for compound 8q as viral replication was rescued from the pyrimidine salvage pathway.

Introduction American military personnel in U.S. Africa Command (AFRICOM) operate in a continent triple the size of the USA without mature medical facilities, requiring a substantial transportation network for medical evacuation. We describe medical transportation based on ophthalmic complaints analyzed from the U.S. Transportation Command Regulating and Command and Control Evacuation System (TRAC2ES) database from 2008 to 2018. Methods We conducted a retrospective review of all TRAC2ES records for medical evacuations for ophthalmic complaints from the AFRICOM theater of operations conducted between January 1, 2008 and December 31, 2018. We analyzed free-text data in TRAC2ES for ophthalmic diagnostic and therapeutic interventions performed before established patient movement requests. An expert panel analyzed evacuations for their indications and interventions. Results Nine hundred and sixty-one total records originating within AFRICOM were identified in TRAC2ES. Forty-three cases (4%) had ophthalmic complaints. The majority of transports were routine (72%) and originated in Djibouti (83%), and all were transported to Landstuhl Regional Medical Center. The majority of patients were evacuated without a definitive diagnosis (60%). Leading ophthalmic diagnoses were chalazion (14%), corneal abrasion/ulcer (14%), and posterior vitreous detachment (12%). More than one-quarter of patients were transported without recorded evaluation and approximately half (51%) did not receive any intervention before evacuation. Consultation with an ophthalmologist occurred in only 16 (37%) cases. By majority, the expert panel deemed 12 evacuations (28%) potentially unnecessary. Conclusion Evacuations were primarily routine often for disease etiology and further diagnostic evaluation. These findings support opportunities for telemedicine consultation to avoid potentially unnecessary transportation. Increased ophthalmic care and enhanced data collection on transports would support process improvement, optimize ophthalmic care by ensuring proper disposition of patients thus limiting unnecessary evacuations, and ultimately strengthen the entire fighting force.

ObjectivesThis project seeks to improve providers’ practices and patient outcomes from prehospital (ie, ambulance-based) trauma care in a middle-income country using a novel implementation strategy to introduce a bundled clinical intervention.DesignWe conduct a two-arm, controlled, mixed-methods, hybrid type II study.SettingThis study was conducted in the Western Cape Government Emergency Medical Services (EMS) system of South Africa.InterventionsWe pragmatically implemented a simplified prehospital bundle of trauma care (with five core elements) using a novel workplace-based, peer-to-peer, rapid training format. We assigned the intervention and control sites.Outcome measuresWe assessed implementation effectiveness among EMS providers and stakeholders, using the RE-AIM framework. Clinical effectiveness was assessed at the patient level, using changes in Shock Index x Age (SIxAge). Indices and cut-offs were established a priori. We performed a difference-in-differences (D-I-D) analysis with a multivariable mixed effects model.Results198 of 240 (82.5%) EMS providers participated, 93 (47%) intervention and 105 (53%) control, with similar baseline characteristics. The overall implementation effectiveness was excellent (80.6%): reach was good (65%), effectiveness was excellent (87%), implementation fidelity was good (72%) and adoption was excellent (87%). Participants and stakeholders generally reported very high satisfaction with the implementation strategy citing that it was a strong operational fit and effective educational model for their organisation. A total of 770 patients were included: 329 (42.7%) interventions and 441 (57.3%) controls, with no baseline differences. Intervention arm patients had more improved SIxAge compared with control at 4 months, which was not statistically significant (−1.4 D-I-D; p=0.35). There was no significant difference in change of SIxAge over time between the groups for any of the other time intervals (p=0.99).ConclusionsIn this quasi-experimental trial of bundled care using the novel workplace rapid training approach, we found overall excellent implementation effectiveness but no overall statistically significant clinical effectiveness.

Introduction The U.S. military currently utilizes unmanned aerial vehicles (UAVs) for reconnaissance and attack missions; however, as combat environment technology advances, there is the increasing likelihood of UAV utilization in prehospital aeromedical evacuation. Although some combat casualties require life-saving interventions (LSIs) during medical evacuation, many do not. Our objective was to describe patients transported from the point of injury to the first level of care and characterize differences between patients who received LSIs en route and those who did not. Materials and Methods We conducted a retrospective review of the records of traumatically injured patients evacuated between January 2011 and March 2014. We compared patient characteristics, complications, and outcomes based on whether they had an LSI performed en route (LSI vs. No LSI). We also constructed logistic regression models to determine which characteristics predict uneventful flights (no en route LSI or complications). Results We examined 1,267 patient records; 47% received an LSI en route. Most patients (72%) sustained a blast injury and injuries to the extremities and head. Over 78% experienced complications en route; the LSI group had higher rates of complications compared to the No LSI group. Logistic regression showed that having a blunt injury or the highest abbreviated injury scale (AIS) severity score in the head/neck region are significant predictors of having an uneventful flight. Conclusion Approximately half of casualties evaluated in our study did not receive an LSI during transport and may have been transported safely by UAV. Having a blunt injury or the highest AIS severity score in the head/neck region significantly predicted an uneventful flight.

IntroductionWithin the Military Health System, the process of transporting patients from an initial point of injury and throughout the entire continuum of care is called “en route care.” A Committee on En Route Combat Casualty Care was established in 2016 as part of the DoD Joint Trauma System to create practice guidelines, recommend training standards, and identify research priorities within the military en route care system.Materials and MethodsFollowing an analysis of currently funded research, future capabilities, and findings from a comprehensive scoping study, members of a sub-working group for research identified the top research priorities that were needed to better guide evidence-based decisions for practice and policy, as well as the future state of en route care.ResultsBased on the input from the entire committee, 10 en route care research topics were rank-ordered in the following manner: (1) medical documentation, (2) clinical decision support, (3) patient monitoring, (4) transport physiology, (5) transfer of care, (6) maintaining normothermia, (7) transport timing following damage control resuscitation or surgery, (8) intelligent tasking, (9) commander’s risk assessment, and (10) unmanned transport. Specific research questions and technological development needs were further developed by committee members in an effort to guide future research and development initiatives that can directly support operational en route care needs. The research priorities reflect three common themes, which include efforts to enhance or increase care provider capability and capacity; understand the impact of transportation on patient physiology; and increase the ability to coordinate, communicate, and facilitate patient movement. Technology needs for en route care must support interoperability of medical information, equipment, and supplies across the global military health system in addition to adjusting to a dynamic transport environment with the smallest possible weight, space, and power requirements.ConclusionsTo ensure an evidence-based approach to future military conflicts and other medical challenges, focused research and technological development to address these 10 en route care research gaps are urgently needed.

Background Recent evidence demonstrates that closed chest compressions directly over the left ventricle (LV) in a traumatic cardiac arrest (TCA) model improve hemodynamics and return of spontaneous circulation (ROSC) when compared to traditional compressions. Selective aortic arch perfusion (SAAP) also improves hemodynamics and controls hemorrhage in TCA. We hypothesized that chest compressions located over the LV would result in improved hemodynamics and ROSC in a swine model of TCA using SAAP. Materials and methods Transthoracic echo was used to mark the location of the aortic root (Traditional location) and the center of the LV on animals (n = 24), which were randomized to receive chest compressions in one of the two locations. After hemorrhage, ventricular fibrillation (VF) was induced to simulate TCA. After a period of 10 min of VF, basic life support (BLS) with mechanical CPR was initiated and performed for 10 min, followed by advanced life support (ALS) for an additional 10 min. SAAP balloons were inflated at min 6 of BLS. Hemodynamic variables were averaged over the final 2 min of the BLS and ALS periods. Survival was compared between this SAAP cohort and a control group without SAAP (No-SAAP) (n = 26). Results There was no significant difference in ROSC between the two SAAP groups (P = 0.67). There was no ROSC difference between SAAP and No-SAAP (P = 0.74). Conclusions There was no difference in ROSC between LV and Traditional compressions when SAAP was used in this swine model of TCA. SAAP did not confer a survival benefit compared to historical controls.

Background Military aeromedical transport evacuates critically injured patients are for definitive care, including patients with or at risk for developing traumatic compartment syndrome of the extremities (tCSoE). Compartment pressure changes of the extremities have not been determined to be associated with factors inherent to aeromedical transport in animal models, but the influence of aeromedical evacuation (AE) transport on the timing of tCSoE development has not been studied in humans. Using a registry-based methodology, this study sought to characterize the temporal features of lower extremity compartment syndrome relative to the timing of transcontinental AE. With this approach, this study aims to inform practice in guidelines relating to the timing and possible effects of long-distance AE and the development of lower extremity compartment syndrome. Using patient care records, we sought to characterize the temporal features of tCSoE diagnosis relative to long-range aeromedical transport. In doing so, we aim to inform practice in guidelines relating to the timing and risks of long-range AE and postulate whether there is an ideal time to transport patients who are at risk for or with tCSoE. Methods We performed a retrospective record review of patients with a diagnosis of tCSoE who were evacuated out of theater from January 2007 to May 2014 via aeromedical transport. Data abstractors collected flight information, laboratory values, vital signs, procedures, in-flight assessments, and outcomes. We used the duration of time from injury to arrival at Landstuhl Regional Medical Center (LRMC) to represent time to transport. We compared groups based on time of tCSoE (inclusive of upper and lower extremity) diagnosis relative to injury day and time of transport (preflight versus postflight). We used descriptive statistics and multivariable regression models to determine the associations between time to transport, time to tCSoE diagnosis, and outcomes. Results Within our study window, 238 patients had documentation of tCSoE. We found that 47% of patients with tCSoE were diagnosed preflight and 53% were diagnosed postflight. Over 90% in both groups developed tCSoE within 48 hours of injury; the time to diagnosis was similar for casualties diagnosed pre- and postflight (P = .65). There was no association between time to arrival at LRMC and day of tCSoE diagnosis (risk ratio, 1.06; 95% CI, 0.96-1.16). Conclusion The timing of tCSoE diagnosis is not associated with the timing of transport; therefore, AE likely does not influence the development of tCSoE.

BackgroundAirway obstruction is the second leading cause of preventable death on the battlefield. Video laryngoscopy has improved airway management in the emergency setting for several decades, and technology continues to improve. Current technology in the supply chain is cost-prohibitive to incorporate at Role 1 facilities, which is where many intubations occur by novice intubators. The i-view is a novel video laryngoscopy device that is handheld, inexpensive, and disposable. The aim of this study was to determine if the i-view is suitable based on performance assessments by physician assistant trainees and survey feedback.Materials and MethodsWe prospectively enrolled physician assistant students at the Interservice Physician Assistant Program at Joint Base San Antonio—Fort Sam Houston. We provided them structured training on how to use the device, and then, a board-certified emergency medicine physician or certified registered nurse anesthetist assessed their intubations performed on a SynDaver mannequin model. We surveyed the participants afterward.ResultsWe enrolled 60 Interservice Physician Assistant Program students. Most participants were male (75%) with a median age of 32 years. Service affiliations included Army (50%), Navy (23%), Air Force (18%), and Coast Guard (8%). Most (70%) had previous deployment experience. All the participants successfully cannulated the mannequins and 98% achieved first-attempt success. Most participants (78%) reported a grade 1 view. On postprocedure survey, 91% strongly agreed with using this device in the deployed setting and 89% strongly agreed with finding it easy to use.ConclusionsAll physician assistant trainees successfully and rapidly performed endotracheal intubation using the disposable i-view video laryngoscope. Study participants rated the device as easy to use and desirable for deployment. Further research is necessary to validate this novel device in the clinical setting before recommending dissemination to the deployed military medical force sets, kits, and outfits.

Exposure to stressors of flight may increase risk of secondary insults among critically injured combat casualties wounded with traumatic brain injury (TBI). The primary objective of this study was to describe the prevalence of hemodynamic events by phase of transport among patients with TBI transported by Critical Care Air Transport Teams (CCATT).We performed a secondary analysis of a retrospective cohort of 477 adults with moderate to severe TBI, who required transport by CCATT to Germany from multiple hospitals in the Middle East between January 2007 and May 2014. We abstracted clinical data from handwritten CCATT medical records. Hemodynamic events included systolic blood pressure100 mm Hg and cerebral perfusion pressure60 mm Hg. We calculated the proportion of patients experiencing hemodynamic events for each phase of flight.We analyzed 404 subjects after exclusions for catastrophic brain injury (n = 39) and missing timestamps (n = 34). Subjects had high Injury Severity Scores (median, 29; interquartile range [IQR], 21-35) and a median flight time of 423 minutes (IQR, 392.5-442.5 minutes). The median of documented in-flight vital signs was 8 measurements (IQR, 6.5-8 measurements). Documented systolic blood pressure in-flight events occurred in 3% of subjects during ascent, 7.9% during early flight, 7.7% during late flight, and 2.2% during descent, with an overall in-flight prevalence of 13.9%. Among patients with intracranial pressure monitoring (n = 120), documented cerebral perfusion pressure events occurred in 5% of subjects during ascent, 23% during early flight, 17% during late flight, and 5.8% during descent, with an overall in-flight prevalence of 30.8%.Documented hemodynamic events occurred during each phase of flight in severely injured combat casualties wounded with TBI, and episodic documentation likely underestimated the actual in-flight frequency of secondary insults.Prognostic and epidemiological; Level IV.

Uncontested air movement and advances for medical care of combat casualties have resulted in a decreased case fatality rate. However, in future large-scale combat operations, the military has established a plan for multidomain operations to defeat near-peer adversaries. Prolonged casualty care and mass casualty scenarios will become more prevalent. Prehospital friendly scoring systems such as the shock index (SI) and revised trauma score (RTS) may provide useful triage data. Development of accurate, data-driven, triage systems will be key to optimize management of resources, care, and transport of combat casualties.We included data from the Department of Defense Trauma Registry between 01 January 2007 to 17 March 2020. Data comprised of adult US military or coalition service members for analysis as the baseline cohort, and those who died within 24 hours were included in the early death cohort. We performed statistical analysis on demographics and injury data, SI and RTS to measure the receiver operating characteristics (ROC) of each value to predict early death.The early death cohort had a significantly higher injury severity score (25 vs. 5) and a higher percentage of serious injuries in every body region than the baseline cohort. The early death cohort sustained serious injuries to the head and neck at a rate five times that of the baseline cohort (43.4% vs 8.1%) with odds ratio (OR) of death 8.0 (95% confidence interval 5.7-11.1) followed by skin (13.6% versus 1.9%) with an OR of 6.3 (95% CI 3.8-10.3). The mean SI was 1.21 versus 0.80. The revised trauma score (RTS) was 4.18 versus 7.34. The RTS had a higher area under the receiver operating characteristic (0.896 versus 0.716 for SI).Serious injuries to the head and skin were most strongly associated with death within the first 24 hours. The RTS appears to be a more accurate tool than SI alone for assessing injury mortality. Military medical personnel should consider these factors when triaging casualties during future conflicts in resource limited settings with delayed evacuation.

The emergency department (ED) poses challenges to effective handoff from emergency medical services (EMS) personnel to ED staff. Despite the importance of a complete and accurate patient handoff report between EMS and trauma staff, communication is often interrupted, incomplete, or otherwise ineffective. TheResearch staff abstracted data from the EMS and inpatient medical records of trauma patients transported by EMS and treated at a Level I trauma center from January 2015 through June 2017. Data included patient demographics, mechanism and location of injury, vital signs, treatments, and period of data collection (pre-MIST and post-MIST). We summarized the MIST elements in EMS and inpatient medical records and assessed the presence or absence of data elements in the inpatient record from the EMS record and the agreement between the two sets of records over time to determine if implementation of MIST improved documentation.We analyzed data from 533 trauma patients transported by EMS and treated in a Level I trauma center (pre-MIST: n = 281; post-MIST: n = 252). For mechanism of injury, agreement between the two records was ≥96% before and after MIST implementation. Cardiac arrest and location of injury were under-reported in the inpatient record before MIST; post-MIST, there were no significant discrepancies, indicating an improvement in reporting. Reporting of prehospital hypotension improved from 76.5% pre-MIST to 83.3% post-MIST. After MIST implementation, agreement between the EMS and inpatient records increased for the reporting of fluid administration (45.6% to 62.7%) and decreased for reporting of pain medications (72.2% to 61.9%).The use of the standardized MIST tool for EMS to hospital patient handoff was associated with a mixed value on inpatient documentation of prehospital events. After MIST implementation, agreement was higher for mechanism and location of injury and lower for vital signs and treatments. Further research can advance the prehospital to treatment facility handoff process.

Introduction Brooke Army Medical Center (BAMC), the largest military hospital and the only level 1 trauma center in the DoD, cares for active duty, retired uniformed services personnel, and beneficiaries. In addition, BAMC works in collaboration with the Southwest Texas Regional Advisory Council (STRAC) and University Hospital (UH), San Antonio’s other level 1 trauma center, to provide trauma care to residents of the city and 22 counties in southwest Texas from San Antonio to Mexico (26,000 square mile area). Civilian-military partnerships are shown to benefit the training of military medical personnel; however, to date, there are no published reports specific to military personnel experiences within emergency care. The purpose of the current study was to describe and compare the emergency department trauma patient populations of two level 1 trauma centers in one metropolitan city (BAMC and UH) as well as determine if DoD level 1 trauma cases were representative of patients treated in OEF/OIF emergency department settings. Materials and Methods We obtained a nonhuman subjects research determination for de-identified data from the US Air Force 59th Medical Wing and the University of Texas Health Science Center at San Antonio Institutional Review Boards. Data on emergency department patients treated between the years 2015 and 2017 were obtained from the two level 1 trauma centers (BAMC and UH, located in San Antonio, Texas); data included injury descriptors, ICU and hospital days, and department procedures. Results Two-proportion Z-tests indicated that trauma patients were similar across trauma centers on injury type, injury severity, and discharge status; yet trauma patients differed significantly in terms of mechanism of injury and regions of injury. BAMC received significantly greater proportions of patients injured from falls, firearms and with facial and head injuries than UH, which received significantly greater proportion of patients with thorax and abdominal injuries. In addition, a significantly greater proportion of patients spent more than 2 days in the ICU and greater than two total hospital days at BAMC than in UH. In comparison to military emergency departments in combat zones, BAMC had significantly lower rates of blood product administration and endotracheal intubations. Conclusions The trauma patients treated at a military level 1 trauma center were similar to those treated in the civilian level 1 trauma center in the same city, indicating the effectiveness of the only DoD Level 1 trauma center to provide experience comparable to that provided in civilian trauma centers. However, further research is needed to determine if the exposure rates to specific procedures are adequate to meet predeployment readiness requirements.

IntroductionHemorrhagic shock is a primary injury amongst combat casualties. Hemorrhagic shock can lead to acute lung injury, which has a high mortality rate. Based on studies showing the role of intense light for organ-protection, we sought to evaluate if intense light pretreatment would be protective in a murine model of hemorrhagic shock lung.Materials and MethodsAfter exposure to standard room light or to intense light (10 000 LUX), mice were hemorrhaged for 90 minutes to maintain a mean arterial pressure (MAP) of 30–35 mmHg. Mice were then resuscitated with their blood and a NaCl infusion at a rate of 0.2 ml/h over a 3-hour period. During resuscitation, blood pressure was recorded. At the end of resuscitation, bronchoalveolar lavage was analyzed for alveolar epithelial barrier function and inflammation. To get insight into the relevance of intense light for humans, we performed a proteomics screen for lung injury biomarkers in plasma from healthy volunteers following intense light therapy.ResultsWe found that intense light pretreated mice had improved hemodynamics and significantly lower albumin, IL-6, and IL-8 levels in their bronchoalveolar lavage than controls. We further discovered that intense light therapy in humans significantly downregulated proinflammatory plasma proteins that are known to cause acute lung injury.ConclusionsOur data demonstrate that mice exposed to intense light before hemorrhagic shock lung have less lung inflammation and improved alveolar epithelial barrier function. We further show that intense light therapy downregulates lung injury promoting proteins in human plasma. Together, these data suggest intense light as a possible strategy to ameliorate the consequences of a hemorrhagic shock on lung injury.

Background Extracorporeal membrane oxygenation (ECMO) is a modification of cardiopulmonary bypass that allows prolonged support of patients with severe respiratory or cardiac failure. ECMO indications arse rapidly evolving and there is growing interest in its use for cardiac arrest and cardiogenic shock. However, ECMO training programs are limited. Training of emergency medicine and critical care clinicians could expand the use of this lifesaving intervention. Our objective was to develop and evaluate an abbreviated ECMO course that can be taught to emergency and critical care physicians and nurses. Methods We developed a training model using Yorkshire swine (Sus scrofa), a procedure instruction checklist, a confidence assessment, and a knowledge assessment. Participants were assigned to teams of one emergency medicine or critical care physician and one nurse and completed an abbreviated 8-hour ECMO course. An ECMO specialist trained participants on preparation of the ECMO circuit and oversaw vascular access and ECMO initiation. We used the instruction checklist to evaluate performance. Participants completed confidence and knowledge assessments before and after the course. Results Seventeen teams (34 clinicians) completed the abbreviated ECMO course. None had previously completed an ECMO certification course. Immediately following the course, all teams successfully primed and prepared the ECMO circuit. Fifteen teams (88%, 95% confidence interval [CI] = 64% to 99%) successfully initiated ECMO. Participants improved their knowledge (difference 21.2, 95% CI = 16.5 to 25.8) and confidence (difference 40.3, 95% CI = 35.6 to 45.0) scores after completing the course. Conclusions We developed an accelerated 1-day ECMO course. Clinicians' confidence and knowledge assessments improved and 88% of teams could successfully initiate venoarterial ECMO after the course.

Hydrogen sulfide (H2 S), a high-threat chemical agent, occurs naturally in a variety of settings. Despite multiple incidents of exposures and deaths, no FDA-approved antidote exists. A rapid-acting, easy to administer antidote is needed. We conducted a randomized control trial in swine comparing intramuscular administration of aminotetrazole cobinamide (2.9 mL, 18 mg/kg) to no treatment following inhalation of H2 S gas. We found that aminotetrazole cobinamide administered 2 min after the onset of respiratory depression-defined as a tidal volume of less than 3 mL/kg for 2 consecutive minutes-yielded 100% survival, while all control animals died. Respiratory depression resolved in the treatment group within 3.6 ± 1.5 min (mean ± SD) of cobinamide administration, whereas control animals had intermittent gasping until death. Blood pressure and arterial oxygen saturation (SO2 ) returned to baseline values within 5 and 10 min, respectively, of cobinamide treatment, and plasma lactate concentration decreased to less than 50% of the highest value by the end of the experiment. In control animals, plasma lactate rose continuously until death. We conclude that intramuscular aminotetrazole cobinamide is effective in a large animal, inhalational model of acute, severe H2 S poisoning.

OBJECTIVES We aimed to describe and evaluate prehospital life-saving interventions performed in a pediatric population in the Afghanistan theater of operations. DESIGN Our study was a post hoc, subanalysis of a larger multicenter, prospective, observational study. SETTING We evaluated casualties enrolled upon admission to one of the nine military medical facilities in Afghanistan between January 2009 and March 2014. PATIENTS Adult and pediatric (

Introduction With personnel scattered throughout a continent 3 times larger than the United States, a lack of mature medical facilities necessitates a significant transportation network for medical evacuation in US Africa Command (AFRICOM). We describe medical evacuations analyzed from the US Air Force Transportation Command Regulating and Command & Control Evacuation System (TRAC2ES). Methods We performed a retrospective review of all TRAC2ES medical records for medical evacuations from the AFRICOM theater of operations conducted between January 1, 2008 and December 31, 2018. We abstracted free text data entry in TRAC2ES for diagnostic and therapeutic interventions performed prior to the patient movement request. Results During this time, there were 963 cases recorded in TRAC2ES originating within AFRICOM. 961 records were complete for analysis. Most patients were male (82%) and military personnel (92%). Most transports originated in Djibouti (72%), and Germany (93%) was the most common destination. Medical evacuations were largely routine (66%), and routine evacuations were proportionally highest amongst US military personnel compared to all other groups. A small portion of patients were evacuated for battle injuries (4%), compared to non-battle injury (33%) and disease (63%). Within disease, the largest proportion of patient complaints centered on gastrointestinal symptoms (13%), behavioral health (11%) and chest pain (8%). Prior to evacuation, only 55% of patients were document as receiving any medication. Pain control was documented in 21% of cases, most commonly being NSAIDs (7%). Discussion Extremely low numbers of battle injuries highlight the unique nature of AFRICOM operations compared to areas with more intense combat operations. Limitations of the dataset highlight the need for a data collection mandate within AFRICOM as within other areas for optimization and performance improvement., African relevance • Original epidemiological study of US Africa Command medical evacuations • Identification of significant US military and civilian medical evacuation trends • Novel analysis of prehospital medical care and evacuation in Africa

ObjectivesKetamine is used as an analgesic for combat injuries. Ketamine may worsen brain injury, but new studies suggest neuroprotection. Our objective was to report the outcomes of combat casualties with traumatic brain injury (TBI) who received prehospital ketamine.MethodsThis was a post hoc, sub-analysis of a larger prospective, multicenter study (the Life Saving Intervention study [LSI]) evaluating prehospital interventions performed in Afghanistan. A DoD Trauma Registry query provided disposition at discharge and outcomes to be linked with the LSI data.ResultsFor this study, we enrolled casualties that were suspected to have TBI (n = 160). Most were 26-year-old males (98%) with explosion-related injuries (66%), a median injury severity score of 12, and 5% mortality. Fifty-seven percent (n = 91) received an analgesic, 29% (n = 46) ketamine, 28% (n = 45) other analgesic (OA), and 43% (n = 69) no analgesic (NA). The ketamine group had more pelvic injuries (P = 0.0302) and tourniquets (P = 0.0041) compared to OA. In comparison to NA, the ketamine group was more severely injured and more likely to require LSI procedures, yet, had similar vital signs at admission and disposition at discharge.ConclusionsWe found that combat casualties with suspected TBI that received prehospital ketamine had similar outcomes to those that received OAs or NAs despite injury differences.

Introduction According to the Military Health System Traumatic Brain Injury (TBI) Center of Excellence, 51,261 service members suffered moderate to severe TBI in the last 21 years. Moderate to severe TBI in service members is usually related to blast injury in combat operations, which necessitates medical evacuation to higher levels of care. Prevention of secondary insult, and mitigation of the unique challenges associated with the transport of TBI patients in a combat setting are important in reducing the morbidity and mortality associated with this injury. The primary goal of this study was a secondary analysis comparing the impact of time to transport on clinical outcomes for TBI patients without polytrauma versus TBI patients with polytrauma transported out of the combat theater via Critical Care Air Transport Teams (CCATT). Our secondary objective was to describe the occurrence of in-flight events and interventions for TBI patients without polytrauma versus TBI with polytrauma to assist with mission planning for future transports. Materials and Methods We performed a secondary analysis of a retrospective cohort of 438 patients with TBI who were evacuated out of theater by CCATT from January 2007 to May 2014. Polytrauma was defined as abbreviated injury scale (AIS) of at least three to another region in addition to head/neck. Time to transport was defined as the time (in days) from injury to CCATT evacuation out of combat theater. We calculated descriptive statistics and examined the associations between time to transport and preflight characteristics, in-flight interventions and events, and clinical outcomes for TBI patients with and without polytrauma. Results We categorized patients into two groups, those who had a TBI without polytrauma (n = 179) and those with polytrauma (n = 259). Within each group, we further divided those that were transported within 1 day of injury, in 2 days, and 3 or more days. Patients with TBI without polytrauma transported in 1 or 2 days were more likely to have a penetrating injury, an open head injury, a preflight Glascow Coma Score (GCS) of 8 or lower, and be mechanically ventilated compared to those transported later. Patients without polytrauma who were evacuated in 1 or 2 days required more in-flight interventions compared to patients without polytrauma evacuated later. Patients with polytrauma who were transported in 2 days were more likely to receive blood products, and patients with polytrauma who were evacuated within 1 day were more likely to have had at least one episode of hypotension en route. Polytrauma patients who were evacuated in 2–3 days had higher hospital days compared to polytrauma with earlier evacuations. There was no significant difference in mortality between any of the groups. Conclusions In patients with moderate to severe TBI transported via CCATT, early evacuation was associated with a higher rate of in-flight hypotension in polytrauma patients. Furthermore, those who had TBI without polytrauma that were evacuated in 1–2 days received more in-flight supplementary oxygen, blood products, sedatives, and paralytics. Given the importance of minimizing secondary insults in patients with TBI, recognizing this in this subset of the population may help systematize ways to minimize such events. Traumatic Brain Injury patients with polytrauma may benefit from further treatment and stabilization in theater prior to CCATT evacuation.

Introduction Hypocalcemia at hospital presentation is associated with increased mortality in trauma patients with hemorrhagic shock. The 2019 updates to the Joint Trauma System Damage Control Resuscitation (DCR) Clinical Practice Guideline recommend calcium supplementation for ionized calcium (iCa) measurements Methods We performed a secondary analysis of a retrospective cohort of patients with moderate-to-severe traumatic brain injury transported by CCATT out of combat theater between January 2007 and May 2014. Additional inclusion criteria included polytrauma and at least one documented in-flight iCa measurement. We categorized exposures based on the minimum in-flight iCa measurement as severe hypocalcemia (iCa Results We analyzed 190 subjects, with a median age of 24 years (interquartile range [IQR] 21 to 29 years) and 97.7% male gender. Explosive injuries (82.1%) and gunshot wounds (6.3%) were the most common mechanisms of injury. The median injury severity score was 34 (IQR 27 to 43). During the flight, 11.6% of patients had severe hypocalcemia, and 39.5% had hypocalcemia. Among patients with any hypocalcemia measurement in-flight (n = 97), 41.2% had hypocalcemia on pre-flight iCa, 28.9% received blood products in-flight, and 23.7% received in-flight calcium supplementation. Only 32.4% of patients with hypocalcemia or severe hypocalcemia in the setting of vasopressor administration received in-flight calcium supplementation. There was no significant difference in mortality between severe hypocalcemia (9.1%), hypocalcemia (5.3%), and never hypocalcemic (3.2%) patients even after controlling for pre-flight variables. Conclusion In-flight hypocalcemia events were common among critically ill combat-wounded polytrauma patients transported by CCATT but were not associated with differences in mortality. Future training should emphasize the need for calcium correction among ERCC patients requiring vasopressors. Future studies with larger sample sizes of patients receiving ERCC are needed to assess the association between in-flight calcium supplementation with clinical outcomes.

Emergency department (ED) utilization continues to climb nationwide resulting in overcrowding, increasing wait times, and a surge in patients with non-urgent conditions. Patients frequently choose the ED for apparent non-emergent medical issues or injuries that after-the-fact could be cared for in a primary care setting. We seek to better understand the reasons why patients choose the ED over their primary care managers.We prospectively surveyed patients that signed into the ED at the Brooke Army Medical Center as an emergency severity index of 4 or 5 (non-emergent triage) regarding their visit. We then linked their survey data to their ED visit including interventions, diagnoses, diagnostics, and disposition by using their electronic medical record. We defined their visit to be non-urgent and more appropriate for primary care, or primary care eligible, if they were discharged home and received no computed tomography (CT) imaging, ultrasound, magnetic resonance imaging (MRI), intravenous (IV) medications, or intramuscular (IM) controlled substances.During the 2-month period, we collected data on 208 participants out of a total of 252 people offered a survey (82.5%). There were 92% (n=191) that were primary care eligible within our respondent pool. Most reported very good (38%) or excellent (21%) health at baseline. On survey assessing why they came, inability to get a timely appointment (n=73), and a self-reported emergency (n=58) were the most common reported reasons. Most would have utilized primary care if they had a next-morning appointment available (n=86), but many reported they would have utilized the ED regardless of primary care availability (n=77). The most common suggestion for improving access to care was more primary care appointment availability (n=96). X-rays were the most frequent study (37%) followed by laboratory studies (20%). Before coming to the ED, 38% (n=78) reported trying to contact their primary care for an appointment. Before coming to the ED, 22% (n=46) reported contacting the nurse advice line. Based on our predefined model, 92% (n=191) of our respondents were primary care eligible within our respondent pool.Patient perceptions of difficulty obtaining appointments appear to be a major component of the ED use for non-emergent visits. Within our dataset, most patients surveyed stated they had difficulty obtaining a timely appointment or self-reported as an emergency. Data suggests most patients surveyed could be managed in the primary care setting.

Objective Preserving air medical evacuation capabilities for critically ill patients with coronavirus disease 2019 (COVID-19) required innovation for en route care logistics, training, and equipment. The aim of this study was to describe characteristics and in-flight interventions for patients with suspected COVID-19 requiring air medical evacuation by US Air Force critical care air transport teams (CCATTs). Methods We performed a retrospective chart review of patients with suspected COVID-19 requiring air medical evacuation by CCATT from April 2020 to February 2021. We included patients with an available CCATT medical record and transport with COVID-19 infection isolation precautions. CCATT medical records were the data source, and we performed descriptive analyses of patient characteristics and in-flight interventions. Results We reviewed 460 records and identified 16 patients for inclusion. The Transport Isolation System (50%) and Negatively Pressurized Conex (31%) were commonly used portable biocontainment units. The median patient age was 48.5 years, and 94% were male. All patients required oxygen supplementation, with 8 (50%) receiving mechanical ventilation. In-flight interventions among intubated patients (n = 8) included vasopressors (50%), paralytics (25%), and patient-ventilator asynchrony management (63%). Conclusion Patients with COVID-19 requiring CCATT transport were older than prior military en route care cohorts, and in-flight interventions for patient-ventilator asynchrony were commonly required during mechanical ventilation.

Academic productivity is a requirement by the Accreditation Council for Graduate Medical Education (ACGME). In addition to the requirements by the ACGME, residency training programs are required to provide education on medical research with the end-goal of teaching physicians how to read, interpret, and apply medical evidence in the form of evidence-based medicine. An understanding of research design, evidencebased medicine, and critical appraisal of available literature is central to practicing medicine and applying new research to clinical practice. However, residency programs vary significantly in research curricula provided to residents. We describe an innovative integrated military-civilian emergency medicine research curriculum that provides foundational knowledge in research design and critical appraisal.

Airway obstruction is the second leading cause of potentially preventable death on the battlefield. Endotracheal intubation is a critical skill needed by emergency military physicians to manage these patients. Our objective is to describe the development of the Defense Registry for Emergency Airway Management (DREAM) at Brooke Army Medical Center (BAMC), a level 1 trauma center over a 7-month period.Emergency physicians (EP) performing endotracheal intubations in the BAMC emergency department (ED) completed standardized data collection forms with information about each event. Trained study team members extracted additional data from the medical records. We cross-referenced each intubation with patient tracking systems in the department and would fill in missing variables through interview with the intubating operator and/or medical records review.The study period comprised January through July 2020. During the study period emergency physicians (EP) performed a total of 74 intubations. Reasons for intubation were related to trauma for 47 patients (64%) and medical conditions for 26 patients (36%). The median age was 51 (interquartile range 30-72) and most were male 48 (65.7%). Difficult airway characteristics encountered included blood in the airway (26%), facial trauma (23%), and airway obstruction (1%). Most intubations utilized video laryngoscopy, and the most frequently used airway devices were Macintosh-shaped (45%) and hyperangulated-shaped (41%). Overall, firstpass success rate was 93% (69) with majority of intubations performed by second-year emergency residents (61%) followed by first-year residents (28%).Most DREAM intubations were related to traumatic injuries. The most frequently encountered difficult airway characteristics were blood in airway and facial trauma. Most intubations were conducted using video laryngoscopy with a high first-pass success rate similar to other published studies. Expansion of the registry to other military emergency departments would enable a data-driven solution for development of individual critical task lists.

Venezuelan equine encephalitis virus (VEEV) is a reemerging alphavirus that can cause encephalitis resulting in severe human morbidity and mortality. Using a high-throughput cell-based screen, we identified a quinolinone compound that protected against VEEV-induced cytopathic effects. Analysis of viral replication in cells identified several quinolinone compounds with potent inhibitory activity against vaccine and virulent strains of VEEV. These quinolinones also displayed inhibitory activity against additional alphaviruses, such as Mayaro virus and Ross River virus, although the potency was greatly reduced. Time-of-addition studies indicated that these compounds inhibit the early-to-mid stage of viral replication. Deep sequencing and reverse genetics studies identified two unique resistance mutations in the nsP2 gene (Y102S/C; stalk domain) that conferred VEEV resistance on this chemical series. Moreover, introduction of a K102Y mutation into the nsP2 gene enhanced the sensitivity of chikungunya virus (CHIKV) to this chemical series. Computational modeling of CHIKV and VEEV nsP2 identified a highly probable docking alignment for the quinolinone compounds that require a tyrosine residue at position 102 within the helicase stalk domain. These studies identified a class of compounds with antiviral activity against VEEV and other alphaviruses and provide further evidence that therapeutics targeting nsP2 may be useful against alphavirus infection.

Point of care ultrasound (POCUS) offers multiple capabilities in a relatively small, lightweight device to military clinicians of all types and levels in multiple environments. Its application in diagnostics, procedural guidance, and patient monitoring has not been fully explored by the Military Health System (MHS). The purpose of this narrative review of the literature was to examine the overall use of POCUS in military settings, as well as the level of ultrasound training provided.Studies related to use of POCUS by military clinicians with reported sensitivity/specificity, accuracy of exam, and/or clinical decision impact met inclusion criteria. After initial topical review and removal of duplicates, two authors selected 17 papers for consideration for inclusion. Four of the authors reviewed the 17 papers and determined the final inclusion of 14 studies.We identified seven prospective studies, of which three randomized subjects to groups. Five reports described use of POCUS in patients, two used healthy volunteers, two were in simulation training environments, four used animal models to simulate specific conditions, and one used a cadaver model. Clinician subjects ranged from one to 34. Conventional medics were subjects in six studies. Four studies included special operations medics. One study included nonmedical food service inspectors. The use of ultrasound in theater by deployed consultant radiologists is described in three reports.Military clinicians demonstrated the ability to perform focused exams, including FAST exams and fracture detection with acceptable sensitivity and specificity. POCUS in the hands of trained military clinicians has the potential to improve diagnostic accuracy and ultimately care of the war fighter.

Head injuries frequently occur in combat. Tactical Combat Casualty Care (TCCC) guidelines recommend pre-hospital use of ketamine for analgesia. Yet the use of this medication in patients with head injuries remains controversial, particularly among pediatric patients. We compare survival to hospital discharge rates among pediatric head injury subjects who received prehospital ketamine versus those who did not.We queried the Department of Defense Trauma Registry (DODTR) for all pediatric (18 years of age) subjects from January 2007 to January 2016. We performed a sub-analysis of subjects with an abbreviated injury severity score for the head of 3 (serious) or higher and at least one documented Glasgow Coma Score (GCS) ≤13.Of the 3439 pediatric patients within our dataset, 555 subjects met inclusion criteria for head injury - 36 (6.5%) received prehospital ketamine versus 519 (93.5%) who did not. There was no significant difference noted between groups regarding median age (10 versus 8, p = 0.259), percent male gender (72.2% versus 76.3%, p = 0.579), mechanism of injury (p = 0.143), median composite injury scores (22 versus 20, p = 0.082), median ventilator-free days (28 versus 27, p = 0.068), median ICU-free days (27.5 versus 27, p = 0.767), median hospital days (3.5 versus 4, p = 0.876) or survival to discharge (66.7% versus 70.7%, p = 0.607).Within this data set, we were unable to detect any differences in mortality among pediatric head trauma subjects administered ketamine compared to subjects not receiving this medication in the prehospital setting.

Survival from traumatic cardiopulmonary arrest (TCA) has been reported at a rate as low as 0-2.6% in the civilian pre-hospital setting, and many consider resuscitation of this group to be futile. The aim of this investigation was to describe patients who received cardiac massage during TCA in a battlefield setting; we also aimed to identify predictors of survival.We conducted a review of the Department of Defense Trauma Registry to identify patients who received cardiac massage in the battlefield between 2007 and 2014. Patients were also grouped according to location of cardiac arrest: pre-hospital (PH) and in-hospital (IH). The groups were compared and evaluated by injury, transport time, type of resuscitation, and pre-hospital procedures. Outcome variables included survival to discharge and 30-day survival. Categorical variables were analysed using chi-square or Fisher's exact tests. Wilcoxon tests were performed for continuous variables. Regression modelling was used to assess for predictors of survival.75 of all 582 patients (13%, 95% CI 10-16) survived to 30 days, and all survivors were transported out of the battlefield; 23 PH (7.8%, 95% CI 5.2-12) and 52 IH (17%, 95% CI 13-22) patients survived to 30 days (p 0.001). Closed-chest cardiac massage with the administration of intravenous medications was associated with 30-day survival among IH patients.We report a 13% survival to 30 days among all patients receiving cardiac massage in a battlefield setting. Closed-chest cardiac massage predicted survival among IH TCA victims who also received intravenous medications in this review of combat-related TCA.

Introduction Critical Care Air Transport Teams (CCATTs) transport critically ill patients within and out of theaters of combat operations. Studies of the CCATT population reveal as many as 35% of patients have a non-trauma diagnosis, of which more than half are cardiac. The purpose of this retrospective study was to describe the epidemiology of critically ill patients with cardiac diagnoses evacuated from theater via CCATT. Materials and Methods We conducted a retrospective review of 290 medical patients with a primary cardiac diagnosis transported from any theater of operation to Landstuhl Regional Medical Center, Germany from January 2007 to April 2015. Results The majority of patients were male with an average age of 46 ± 11 years, US contractors (47%, n = 137), followed by US Active Duty (32%, n = 93). Patients had an average BMI of 29 ± 5; 62% of cardiac patients were either overweight or obese. The most common cardiac diagnoses were ST elevation myocardial infarction, Non-ST elevation myocardial infarction, and angina. Pre-flight vital signs indicate overall patients were stable prior to evacuation, with the majority receiving supplemental oxygen and only 5% requiring mechanical ventilation. Eighty-one percent of patients experienced at least one cardiac event during flight, however less than 5% required adjustment to oxygen or ventilator settings. Conclusions Critically ill cardiac patients make up a significant portion of patients transported out of the combat theater. These patients are older, overweight and have identified risk factors for cardiac morbidity. More strenuous pre-deployment screening for risk factors and prevention strategies could minimize the use of military resources to evacuate these patients from the combat theater.

Early, non-clinical studies support the use of hydroxocobalamin to treat sepsis-induced hypotension, but there is no translational, large animal model. The objective of this study was to compare survival in a sepsis model where large swine had endotoxaemia induced with lipopolysaccharide (LPS) and were treated with intravenous hydroxocobalamin (HOC), noradrenaline (NA), or saline. Thirty swine (45-55 kg) were anaesthetized, intubated, and instrumented with continuous femoral and pulmonary artery pressure monitoring. Hypotension, predefined as 50% of baseline, was induced with LPS. Animals then received HOC, NA, or saline and monitored for 3 hours. The main outcome was survival to the conclusion of the study. Using a power of 80% and an alpha of 0.05, 10 animals were used per group. Secondary outcomes included: mean arterial pressure (MAP), systemic vascular resistance (SVR) and cardiac output (CO) along with several markers of sepsis. No differences were detected between groups at baseline or after hypotension. The survival distributions of the three groups were significantly different with more HOC animals surviving (10/10) compared with NA (8/10) or Saline (5/10) (log-rank P

Background: Women served in both combat and non-combat units in the recent conflicts in Iraq and Afghanistan. Moreover, the recent conflicts lacked traditional separation of civilians from combatants carrying additional risk for injury to local civilians. There is a relative paucity of data specific to this topic. We compare injury patterns and interventions performed in the prehospital, combat setting among females versus males. Methods: This is a secondary analysis of previously published data from the Department of Defense Trauma Registry. We included all subjects that had at least one prehospital intervention documented. We compared variables between females and males. Results: From January 2007 to August 2016, our inclusion criteria captured 19,485 males and 533 females. Female casualties were older (median age 29 vs. 25), less likely to have sustained injuries from explosives (48.0% vs. 56.8%), and more severely injured as measured by median composite injury scores (10 vs. 9). Most subjects were in Afghanistan for both females and males (52.9% vs. 73.9%). Among United States (US) service members, findings were similar to the overall study population, except female service members had lower median composite injury scores than males (5 vs. 9). In unadjusted analyses, females were less likely to survive to hospital discharge (OR 0.68, 95% CI 0.48-0.97). There was no difference in survival (OR 0.73, 95% CI 0.50-1.07), when controlling for confounders. In both unadjusted and adjusted analyses specific to US forces, we were unable to detect any differences in survival or for select analgesic administration. In both unadjusted and adjusted analyses specific to host nation civilians, we were unable to detect any differences in survival; however, even when controlling for confounders females were less likely to receive ketamine and IV morphine (OR 0.31, 95% CI 0.15-0.63; 0.69, 95% CI 0.49-0.98, respectively). Conclusions: Females accounted for a small proportion of total casualties within our dataset. After controlling for confounders, survival was comparable between males and females, but host nation females were less likely to receive ketamine and intravenous morphine. Future studies should seek to elucidate the reasons for these subtle differences between males and females in prehospital combat casualty care.