Search

Introduction: Airway obstruction is the second leading cause of death on the battlefield. The harsh conditions of the military combat setting require that devices be able to withstand extreme circumstances. Military standards (MIL-STD) testing is necessary before devices are fielded. We sought to determine the ability of supraglottic airway (SGA) devices to withstand MIL-STD testing., Methods: We tested 10 SGA models according to nine MIL-STD-810H test methods. We selected these tests by polling five military and civilian emergency-medicine subject matter experts (SMEs), who weighed the relevance of each test. We performed tests on three devices for each model, with operational and visual examinations, to assign a score (1 to 10) for each device after each test. We calculated the final score of each SGA model by averaging the score of each device and multiplying that by the weight for each test, for a possible final score of 2.6 to 26.3., Results: The scores for the SGA models were LMA Classic Airway, 25.9; AuraGain Disposable Laryngeal Mask, 25.5; i-gel Supraglottic Airway, 25.2; Solus Laryngeal Mask Airway, 24.4; LMA Fastrach Airway, 24.4; AuraStraight Disposable Laryngeal Mask, 24.1; King LTS-D Disposable Laryngeal Tube, 22.1; LMA Supreme Airway, 21.0; air-Q Disposable Intubating Laryngeal Airway, 20.1; and Baska Mask Supraglottic Airway, 18.1. The limited (one to three) samples available for testing provide adequate preliminary information but restrict the range of failures that could be discovered., Conclusions: Lower scoring SGA models may not be optimal for military field use. Models scoring sufficiently close to the top performers (LMA Classic, AuraGain, i-gel, Solus, LMA Fastrach, AuraStraight) may be viable for use in the military setting. The findings of our testing should help guide device procurement appropriate for different battlefield conditions., (2023.)

Background: The battalion aid station (BAS) has historically served as the first stop during which combat casualties would receive care beyond a combat medic. Since the conflicts in Iraq and Afghanistan, many combat casualties have bypassed the BAS for treatment facilities capable of surgery. We describe the care provided at these treatment facilities during 2007-2020., Methods: This is a secondary analysis of previously described data from the Department of Defense Trauma Registry. We included encounters with the documentation of an assessment or intervention at a BAS or forward operating base from January 1, 2007 to March 17, 2020. We utilized descriptive statistics to characterize these encounters., Results: There were 28,950 encounters in our original dataset, of which 3.1% (884) had the documentation of a prehospital visit to a BAS. The BAS cohort was older (25 vs. 24, P < .001) The non-BAS cohort saw a larger portion of pediatric (<18 years) patients (10.7% vs. 5.7%, P < .001). A higher proportion of BAS patients had nonbattle injuries (40% vs. 20.7%, P < .001). The mean injury severity score was higher in the non-BAS cohort (9 vs. 5, P < .001). A higher proportion of the non-BAS cohort had more serious extremity injuries (25.1% vs. 18.4%, P < .001), although the non-BAS cohort had a trend toward serious injuries to the abdomen (P = .051) and thorax (P = .069). There was no difference in survival., Conclusions: The BAS was once a critical point in casualty evacuation and treatment. Within our dataset, the overall number of encounters that involved a stop at a BAS facility was low. For both the asymmetric battlefield and multidomain operations/large-scale combat operations, the current model would benefit from a more robust capability to include storage of blood, ventilators, and monitoring and hold patients for an undetermined amount of time., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

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: Airway obstruction is the second leading cause of preventable death on the battlefield. Most airway obstruction occurs secondary to traumatic disruptions of the airway anatomical structures. Facial trauma is frequently cited as rationale for maintaining cricothyrotomy in the medics' skill set over the supraglottic airways more commonly used in the civilian setting., Methods: We used a series of emergency department procedure codes to identify patients within the Department of Defense Trauma Registry (DoDTR) from January 2007 to August 2016. This is a sub-group analysis of casualties with documented serious facial trauma based on an abbreviated injury scale of 3 or greater for the facial body region., Results: Our predefined search codes captured 28,222 DoDTR casualties, of which we identified 136 (0.5%) casualties with serious facial trauma, of which 19 of the 136 had documentation of an airway intervention (13.9%). No casualties with serious facial trauma underwent nasopharyngeal airway (NPA) placement, 0.04% underwent cricothyrotomy (n = 10), 0.03% underwent intubation (n = 9), and a single subject underwent supraglottic airway (SGA) placement (<0.01%). We only identified four casualties (0.01% of total dataset) with an isolated injury to the face., Conclusions: Serious injury to the face rarely occurred among trauma casualties within the DoDTR. In this subgroup analysis of casualties with serious facial trauma, the incidence of airway interventions to include cricothyrotomy was exceedingly low. However, within this small subset the mortality rate is high and thus better methods for airway management need to be developed., (2022.)

Introduction: Opioids carry high risk of dependence, and patients can rapidly build tolerance after repetitive dosing. Low-dose ketamine is an analgesic agent alternative that provides more hemodynamic stability. We sought to describe the effects of prolonged ketamine use in non-burn patients., Materials and Methods: We queried the electronic health system at the Brooke Army Medical Center for patient encounters with ketamine infusions lasting >72 hours. We abstracted data describing demographics, vital signs, ketamine infusion dose and duration, and discharge diagnoses potentially relevant to ketamine side effects., Results: We identified 194 subjects who met the study inclusion criteria. The median age was 39 years, most were male (67.0%), and most were primarily admitted for a non-trauma reason (59.2%). The mean ketamine drip strength was 43.9 mg/h (95% CI, 36.7-51.1; range 0.1-341.6) and the mean drip length was 130.8 hours (95% CI, 120.3-141.2; range 71-493). Most subjects underwent mechanical ventilation (56.1%) at some point during the infusion and most survived to hospital discharge (83.5%). On a per-day basis, the average heart rate was 93 beats per minute, systolic blood pressure was 128 mmHg, diastolic blood pressure was 71 mmHg, oxygen saturation was 96%, and respiratory rate was 22 respirations per minute., Conclusions: We demonstrate that continuous ketamine infusions provide a useful adjunct for analgesia and/or sedation. Further development of this adjunct modality may serve as an alternative agent to opioids., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Background: Airway 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 Methods: We 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., Results: We 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., Conclusions: All 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., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2020. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Background: Most potentially preventable deaths occur in the prehospital setting before reaching a military treatment facility with surgical capabilities. Thus, optimizing the care we deliver in the prehospital combat setting represents a ripe target for reducing mortality. We sought to analyze prehospital data within the Department of Defense Trauma Registry (DODTR). Materials and methods: We requested all encounters with any prehospital activity (e.g., interventions, transportation, vital signs) documented within the DODTR from January 2007 to March 2020 along with all hospital-based data that was available. We excluded from our search casualties that had no prehospital activity documented. Results: There were 28,950 encounters that met inclusion criteria. Of these, 25,897 (89.5%) were adults and 3053 were children (10.5%). There was a steady decline in the number of casualties encountered with the most notable decline occurring in 2014. U.S. military casualties comprised the largest proportion (n = 10,182) of subjects followed by host nation civilians (n = 9637). The median age was 24 years (interquartile range/IQR 21-29). Most were battle injuries (78.6%) and part of Operation ENDURING FREEDOM (61.8%) and Operation IRAQI FREEDOM (24.4%). Most sustained injuries from explosives (52.1%) followed by firearms (28.1%), with serious injury to the extremities (24.9%) occurring most frequently. The median injury severity score was 9 (IQR 4-16) with most surviving to discharge (95.0%). A minority had a documented medic or combat lifesaver (27.9%) in their chain of care, nor did they pass through an aid station (3.0%). Air evacuation predominated (77.9%). Conclusions: Within our dataset, the deployed U.S. military medical system provided prehospital medical care to at least 28,950 combat casualties consisting mostly of U.S. military personnel and host nation civilian care. There was a rapid decline in combat casualty volumes since 2014, however, on a per-encounter basis there was no apparent drop in procedural volume.

Background: The US military has been engaged in the Global War on Terrorism for nearly 2 decades. This asymmetric warfare has exposed many noncombat military occupational specialties (MOS) personnel to combat. We assessed what proportion of casualties were combat versus noncombat MOS personnel., Methods: This is a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry (DODTR). We included US military casualties sustaining battle injuries from January 2007 to March 2020 with a documented MOS. We classified each casualty as combat versus noncombat MOS personnel., Results: There were 2,037 casualties who met inclusion for this analysis. Within these groups, there were 1,554 (76%) combat and 483 (24%) noncombat personnel. The median ages were 24 and 25, with more males among the combat MOS personnel (99% versus 93%). Army personnel comprised the largest proportion of both groups (78% versus 75%) with most injured by explosive (73% versus 78%). Median injury severity scores were similar (9 in both groups) as was survival (98% versus 98%). The annual proportion of battle injuries comprised of noncombat MOS personnel fluctuated year-to-year. The proportion of noncombat personnel with a medic in their chain of care was similar to combat personnel (25% versus 26%), as was the proportion undergoing medical evacuation by ground (11% versus 11%) or air (87% versus 86%). All prehospital interventions occurred in similar proportions except for ketamine administration (8% combat versus 3% noncombat MOS personnel)., Conclusions: Our study showed noncombat MOS personnel comprised nearly one in four casualties. Injury patterns were similar between combat and noncombat MOS personnel with nearly identical consumption of resources except for ketamine. More data is necessary on noncombatant MOS personnel battle injury patterns to guide commanders and medical leaders for future mission planning in resource constrained environments.

Introduction: Role 1 care is vital to patient survival and includes many echelons of care from point-of-injury first aid to medical attention at battalion aid stations. Many guidelines are written for Role 1 care providers to optimize care for different scenarios. Differences in the guidelines lead to confusion and discrepancies between the types of treatment medical care providers provide. Although the guidelines were written for different areas of care, uniformity between the guidelines is needed and will lead to a reduced mortality rate., Materials and Methods: It was determined that the Tactical Combat Casualty Care Guidelines, Prolonged Field Care Guidelines, Joint Trauma System Clinical Practice Guidelines, and Standard Medical Operating Guidelines from medical evacuation were the military medical guidelines most relevant to Role 1 care. These Guidelines were compared side by side to determine the differences between them., Results: Although the guidelines were largely similar, many major differences were found between them. Our online tables contain large inconsistences between guidelines including direct contradictions in conversion of junctional tourniquets and the administration of tranexamic acid., Conclusions: Role 1 care is vital to patient survival, including care from point of injury to battalion aid stations, but the guidelines available to instruct this care and the guidance on which personnel should provide this care are conflicting. This lack of clarity and consistency may adversely impact treatment outcomes. The reduction or elimination of conflicting information across the various guidelines, augmentation of guidance for pediatric care, more specific guidance for unique levels of care, and clearer delineation of the Role 1 phases of care (as well as which guidelines are most appropriate to each) should be considered as urgent priorities within the military medical community., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2020. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Objectives: The coronavirus disease 2019 (COVID-19) pandemic has resulted in unprecedented hospitalizations, ventilator use, and deaths. Because of concerns for resource utilization and surges in hospital capacity use, Texas Executive Order GA-29 required statewide mask wear beginning July 3, 2020. Our objective was to compare COVID-19 case load, hospital bed use, and deaths before and after implementation of this mask order., Methods: This was a retrospective observational study using publicly reported statewide data to perform a mixed-methods interrupted time series analysis. We compared outcomes before and after the statewide mask wear mandate per Executive Order GA-29. The preorder period was from June 19 to July 2, 2020. The postorder period was July 17 to September 17, 2020. Outcomes included daily COVID-19 case load, hospitalizations, and mortality., Results: The daily case load before the mask order per 100,000 individuals was 187.5 (95% confidence interval [CI] 157.0-217.0) versus 200.7 (95% CI 179.8-221.6) after GA-29. The number of daily hospitalized patients with COVID-19 was 171.4 (95% CI 143.8-199.0) before GA-29 versus 225.1 (95% CI 202.9-247.3) after. Daily mortality was 2.4 (95% CI 1.9-2.9) before GA-29 versus 5.2 (95% CI 4.6-5.8). There was no material impact on our results after controlling for economic activity., Conclusions: In both adjusted and unadjusted analyses, we were unable to detect a reduction in case load, hospitalization rates, or mortality associated with the implementation of an executive order requiring a statewide mask order. These results suggest that during a period of rapid virus spread, additional public health measures may be necessary to mitigate transmission at the population level.

Introduction: The Prehospital Trauma Registry (PHTR) captures after-action reviews (AARs) as part of a continuous performance improvement cycle and to provide commanders real-time feedback of Role 1 care. We have previously described overall challenges noted within the AARs. We now performed a focused assessment of challenges with regard to hemodynamic monitoring to improve casualty monitoring systems., Materials and Methods: We performed a review of AARs within the PHTR in Afghanistan from January 2013 to September 2014 as previously described. In this analysis, we focus on AARs specific to challenges with hemodynamic monitoring of combat casualties., Results: Of the 705 PHTR casualties, 592 had available AAR data; 86 of those described challenges with hemodynamic monitoring. Most were identified as male (97%) and having sustained battle injuries (93%), typically from an explosion (48%). Most were urgent evacuation status (85%) and had a medical officer in their chain of care (65%). The most common vital sign mentioned in AAR comments was blood pressure (62%), and nearly one-quarter of comments stated that arterial palpation was used in place of blood pressure cuff measurements., Conclusions: Our qualitative methods study highlights the challenges with obtaining vital signs-both training and equipment. We also highlight the challenges regarding ongoing monitoring to prevent hemodynamic collapse in severely injured casualties. The U.S. military needs to develop better methods for casualty monitoring for the subset of casualties that are critically injured., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2020. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Objectives: Coronavirus disease 2019 (COVID-19) threatens vulnerable patient populations, resulting in immense pressures at the local, regional, national, and international levels to contain the virus. Laboratory-based studies demonstrate that masks may offer benefit in reducing the spread of droplet-based illnesses, but few data are available to assess mask effects via executive order on a population basis. We assess the effects of a county-wide mask order on per-population mortality, intensive care unit (ICU) utilization, and ventilator utilization in Bexar County, Texas., Methods: We used publicly reported county-level data to perform a mixed-methods before-and-after analysis along with other sources of public data for analyses of covariance. We used a least-squares regression analysis to adjust for confounders. A Texas state-level mask order was issued on July 3, 2020, followed by a Bexar County-level order on July 15, 2020. We defined the control period as June 2 to July 2 and the postmask order period as July 8, 2020-August 12, 2020, with a 5-day gap to account for the median incubation period for cases; longer periods of 7 and 10 days were used for hospitalization and ICU admission/death, respectively. Data are reported on a per-100,000 population basis using respective US Census Bureau-reported populations., Results: From June 2, 2020 through August 12, 2020, there were 40,771 reported cases of COVID-19 within Bexar County, with 470 total deaths. The average number of new cases per day within the county was 565.4 (95% confidence interval [CI] 394.6-736.2). The average number of positive hospitalized patients was 754.1 (95% CI 657.2-851.0), in the ICU was 273.1 (95% CI 238.2-308.0), and on a ventilator was 170.5 (95% CI 146.4-194.6). The average deaths per day was 6.5 (95% CI 4.4-8.6). All of the measured outcomes were higher on average in the postmask period as were covariables included in the adjusted model. When adjusting for traffic activity, total statewide caseload, public health complaints, and mean temperature, the daily caseload, hospital bed occupancy, ICU bed occupancy, ventilator occupancy, and daily mortality remained higher in the postmask period., Conclusions: There was no reduction in per-population daily mortality, hospital bed, ICU bed, or ventilator occupancy of COVID-19-positive patients attributable to the implementation of a mask-wearing mandate.

Background: United States Africa Command (US AFRICOM) is one of six US Defense Department's geographic combatant commands and is responsible to the Secretary of Defense for military relations with African nations, the African Union, and African regional security organizations. A full-spectrum combatant command, US AFRICOM is responsible for all US Department of Defense operations, exercises, and security cooperation on the African continent, its island nations, and surrounding waters. We seek to characterize blood product administration within AFRICOM using the in-transit visibility tracking tool known as TRAC2ES (TRANSCOM Regulating and Command & Control Evacuation System)., Methods: We performed a retrospective review of TRAC2ES medical evacuations from the AFRICOM theater of operations conducted between 1 January 2008 and 31 December 2018., Results: During this time, there were 963 cases recorded in TRAC2ES originating within AFRICOM, of which 10 (1%) cases received blood products. All patients were males. One was a Department of State employee, one was a military working dog, and the remainder were military personnel. Of the ten humans, seven were the result of trauma, most by way of gunshot wound, and three were due to medical causes. Among human subjects receiving blood products for traumatic injuries, a total of 5 units of type O negative whole blood, 29 units of packed red blood cells (pRBCs), and 9 units of fresh frozen plasma (FFP) were transfused. No subjects underwent massive transfusion of blood products, and only one subject received pRBCs and FFP in 1:1 fashion. All subjects survived until evacuation., Conclusions: Within the TRAC2ES database, blood product administration within AFRICOM was infrequent, with some cases highlighting lack of access to adequate blood products. Furthermore, the limitations within this database highlight the need for systems designed to capture medical care performance improvement, as this database is not designed to support such analyses. A mandate for performance improvement within AFRICOM that is similar to that of the US Central Command would be beneficial if major improvements are to occur., (2021.)

Background: Battlefield first responders (BFR) are the first non-medical personnel to render critical lifesaving interventions for combat casualties, especially for massive hemorrhage where rapid control will improve survival. Soldiers receive medical instruction during initial entry training (IET) and unit-dependent medical training, and by attending the Combat Lifesaver (CLS) course. We seek to describe the interventions performed by BFRs on casualties with only BFRs listed in their chain of care within the Prehospital Trauma Registry (PHTR)., Methods: This is a secondary analysis of a dataset from the PHTR from 2003-2019. We excluded encounters with a documented medical officer, medic, or unknown prehospital provider at any time in their chain of care during the Role 1 phase to isolate only casualties with BFR medical care., Results: Of the 1,357 encounters in our initial dataset, we identified 29 casualties that met inclusion criteria. Pressure dressing was the most common intervention (n=12), followed by limb tourniquets (n=4), IV fluids (n=3), hemostatic gauze (n=2), and wound packing (n=2). Bag-valve-masks, chest seals, extremity splints, and nasopharyngeal airways (NPA) were also used (n=1 each). Notably absent were backboards, blizzard blankets, cervical collars, eye shields, pelvic splints, hypothermia kits, chest tubes, supraglottic airways (SGA), intraosseous (I/O) lines, and needle decompression (NDC)., Conclusions: Despite limited training, BFRs employ vital medical skills in the prehospital setting. Our data show that BFRs largely perform medical interventions within the scope of their medical knowledge and training. Better datasets with efficacy and complication data are needed.

Background: A novel video laryngoscope device, the i-view, may extend intubation capability to the lowest echelons of deployed military medicine. The i-view is a one-time use, disposable laryngoscope. We compared time to completion of endotracheal intubation (ETI) between the i-view and GlideScope among military emergency medicine providers in a simulation setting., Methods: We conducted a prospective, randomized, crossover trial. We randomized participants to i-view or GlideScope first before they performed 2 ETI-1 with each device. The primary outcome was time to completion of ETI. Secondary outcomes included first-pass success, optimal glottic view, and end-user appraisal. We used a Laerdal Airway Management Trainer for all intubations., Results: Thirty-three emergency medicine providers participated. ETI time was less with GlideScope than i-view (22.2 +/- 9.0 seconds versus 30.2 +/- 24.0 seconds; p=0.048). Optimal glottic views, using the Cormack-Lehan scale, also favored the GlideScope (2 [1,2] versus 2[2,2]; p=0.044). There was no difference in first-pass success rates (100% versus 100%). More participants preferred the GlideScope (24 versus 9; p=0.165); however, participants agreed that the i-view would be easier to use than the GlideScope in an austere environment (4[4,5])., Conclusions: We found the GlideScope outperformed the i-view with respect to procedural completion time. Participants preferred the GlideScope over i-view, but indicated the i-view would be easier to use than the GlideScope in an austere setting. Our findings suggest the i-view may be a suitable alternative to GlideScope for US military providers, especially for those in the prehospital setting.

Background: Most battlefield deaths occur in the prehospital setting prior to reaching surgical and hospital care. Described are casualties captured by the Joint Trauma System (JTS) in the Prehospital Trauma Registry (PHTR) module of the Department of Defense Trauma Registry (DoDTR), from inception through May 2019., Methods: The JTS was queried for all PHTR encounters and associated data from inception (January 2003) through May 2019. The PHTR captures data on Role 1 prehospital care which encompasses treatment prior to arrival at a Role 2 with or without forward surgical team or Role 3 combat support hospital. Two unique patient identifiers were used to link DODTR outcome data to each PHTR encounter. Descriptive statistics were used to analyze the data., Results: We obtained a total of 1,357 encounters from the PHTR. Of these encounters, we successfully linked 52.2% (709/1357) to the DODTR for outcome data. Encounters spanned from 2003 to 2019, with most (69.5%) occurring from 2012 to 2014. Many casualties were in the 18-25 (25.5%) or 26-33 (27.0%) age ranges, male (99.2%), injured by explosive (47.1%) or firearm (34.8%), enlisted (44.8%), and US military conventional (24.1%) and special operations (23.9%) forces. Of those linked to the DODTR, demographics were similar, most casualties sustained battle injuries (87.1%), the majority of which survived (99.1%)., Conclusions: We described 1,357 encounters within the PHTR, most of which were US casualties and casualties injured by explosives. This renewed effort by the JTS to capture more casualties for inclusion into the registry has nearly doubled the proportion of available encounters for analysis. This analysis lays the foundation for in-depth analyses targeting areas for optimizing Role 1 prehospital combat casualty care.

Background: Extended Focused Assessment with Ultrasonography in Trauma (eFAST) reliably identifies noncompressible torso hemorrhage (NCTH), a major cause of battlefield death. Increased portability of ultrasound enables eFAST far forward on the battlefield, and published data demonstrate combat medics can learn and reliably perform ultrasound exams. One medical company developed an ultrasound device with an intuitive graphical user interface (GUI) and novel, finger-worn transducer with built-in linear and phased arrays, referred to as the novel device. We evaluated combat medic eFAST performance between the novel and conventional device., Methods: This was a prospective, randomized, crossover trial completed at a single US military installation. Subjects were US Army combat medics with no previous ultrasound experience. Subjects performed an eFAST on a live human and a simulation model with both devices after a brief training intervention. Our primary outcome was time in seconds for eFAST completion, limited to 600 seconds. Secondary outcomes included diagnostic accuracy, technical adequacy using a validated task-specific checklist, and end-user appraisal of device ease-of-use with 5-point Likert items. This study was approved by the local institutional review board., Results: Forty subjects volunteered, most were male (67.5%), less than 36 years old (95.0%), and grade E-4 or below (75.0%). Subjects performed a total of 160 eFAST scans (80 novel, 80 conventional). We found no significant difference in time for eFAST completion between the novel and conventional devices (391 seconds [95% CI 364, 417] versus 352 seconds [95% CI 325, 379]; p = 0.71). We also found no significant differences between the novel and conventional devices with respect to diagnostic accuracy (91.5% versus 89.2%; p = 0.28) and technical adequacy (75.0% versus 72.5%; p = 0.28). However, we did find that subjects favored the image quality of the novel device (4.3 versus 3.6; p is less than 0.01), while favoring the conventional transducer (3.8 versus 4.3; p = 0.04)., Conclusion: Combat medic eFAST performance utilizing both devices did not differ with respect to time to completion, diagnostic accuracy, and technical adequacy. Medics with limited ultrasound experience performed diagnostically accurate eFAST after a brief training intervention. Future research should assess learning gaps and skill retention in order to guide development of US military ultrasound training programs for combat medics.

Introduction: Identifying patients at imminent risk of death is a paramount priority in combat casualty care. This study measures the vital sign values predictive of mortality among combat casualties in Iraq and Afghanistan., Methods: We used data from the Department of Defense Trauma Registry from January 2007 to August 2016. We used the highest documented heart rate and the lowest documented systolic pressure in the emergency department for each casualty. We constructed receiver operator curves (ROCs) to assess the accuracy of these variables for predicting survival to hospital discharge., Results: There were 38,769 encounters of which our dataset included 15,540 (40.1%). The median age of these patients was 25 years and 97.5% were male. The most common mechanisms of injury were explosives (n = 9481, 61.0%) followed by gunshot wounds (n = 2393, 15.3%). The survival rate to hospital discharge was 97.5%. The median heart rate was 94 beats per minute (bpm) with area under the ROC of 0.631 with an optimal threshold to predict mortality of 110 bpm (sensitivity 52.2%, specificity 79.2%). The median systolic blood pressure was 128 mmHg with area under the ROC of 0.790 with an optimal threshold to predict mortality of 112 mmHg (sensitivity 68.5%, specificity 81.5%)., Conclusions: Casualties with a systolic blood pressure <112 mmHg, are at high risk of mortality, a value significantly higher than the traditional 90 mmHg threshold. Our dataset highlights the need for better methods to guide resuscitation as vital sign measurements have limited accuracy in predicting mortality., Competing Interests: Declaration of competing interest We have no conflicts to report., (Published by Elsevier Inc.)

Introduction: The Committee on Tactical Combat Casualty Care and Capabilities Development and Integration Directorate cite airway burn injuries as an indication for prehospital cricothyrotomy. We sought to build on previously published data by describing for the first time the incidence of prehospital airway interventions in combat casualties who received airway management in the setting of inhalational injuries.15,26 We hypothesized that (1) airway interventions in combat casualties who suffered inhalational injury would have a higher mortality rate than those without airway intervention and (2) prehospital cricothyrotomy was used with greater incidence than endotracheal intubation., Materials and Methods: Using a previously described Department of Defense Trauma Registry dataset from January 2007 to August 2016, unique casualties with documented inhalational injury were identified., Results: Our predefined search codes captured 28,222 (72.8% of all encounters in the registry) of those subjects. A total of 347 (1.2%) casualties had a documented inhalational injury, 27 (7.8%) of those with at least 1 prehospital airway intervention inhalational injuries (0.09% of our dataset [n = 28,222]). Within the subset of patients with an inhalation injury, 23 underwent intubation, 2 underwent cricothyrotomy, 3 had placement of an airway adjunct not otherwise specifically listed, and 1 casualty had both a cricothyrotomy and intubation documented. No casualties had a supraglottic, nasopharyngeal, or oropharyngeal airway listed. Contrary to our hypotheses, of those with an airway intervention, 74.0% survived to hospital discharge. In multivariable regression models, when adjusting for confounders, there was no difference in survival to discharge in those with an airway intervention compared to those without., Conclusions: Casualties undergoing airway intervention for inhalation injuries had similar survival adjusting for injury severity, supporting its role when indicated. Without case-specific data on airway status and interventions, it is challenging to determine if the low rate of cricothyrotomy in this population was a result of rapid transport to a more advanced provider capable of performing intubation or cricothyrotomy may not be meeting the needs of the medics., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2020. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Background: Personal protective equipment (PPE) is crucial to force protection and preservation. Innovation in PPE has shifted injury patterns, with protected body regions accounting for decreased proportions of battlefield trauma relative to unprotected regions. Little is known regarding the PPE in use by warfighters at the time of injury., Methods: We queried the Prehospital Trauma Registry (PHTR) for all encounters from 2003-2019. This is a sub-analysis of casualties with documented PPE at the time of medical encounter. When possible, encounters were linked to the Department of Defense Trauma Registry (DODTR) for outcome data. Serious injuries are defined as an abbreviated injury scale of 3 or greater., Results: Of 1,357 total casualty encounters in the PHTR, 83 were US military with documented PPE. We link 62 of this cohort to DODTR. The median composite Injury Severity Score (ISS) was 6 (Interquartile range (IQR) 4-21), and 11 casualties (18%) had an ISS >25. The most seriously injured body regions were the extremities (21%), head/neck (16%), thorax (16%), and abdomen (10%). PPE worn at time of injury included helmet (91%), eye protection (73%), front (75%) and rear plates (77%), left/right plates (65%), tactical vest (46%), groin protection (12%), neck protection (6%), pelvic shield (3%), and deltoid protection (3%)., Conclusion: Our data set demonstrates that the extremities were the most commonly injured body region, followed by head/neck, and thorax. PPE designed for the extremities and neck are also among the least commonly worn protective equipment.

Introduction: Hemorrhage is the leading cause of potentially preventable death on the battlefield. The tactical combat casualty care guidelines recommend the use of the radial pulse strength to guide the administration of blood products or intravenous fluids when equipment for blood pressure monitoring is not available. Data supporting this measurement tool are limited. We sought to validate this method in a deployed trauma population., Materials and Methods: This is a secondary analysis of a previously published dataset from the Department of Defense Trauma Registry. In this subanalysis, we focused on emergency department radial pulse strength documented in conjunction with systolic blood pressure readings., Results: Our predefined search codes captured 28,222 Department of Defense Trauma Registry casualties. Of those, 22,192 casualties had at least 1 radial pulse strength documented, with a total of 27,366 documented measurements total among the 22,192. The median age of casualties was 25 years, most were male (96.8%), U.S. military made up the largest proportion (44.2%), most were injured by explosive (55.8%), and most were in Afghanistan (67.0%) with a median injury severity score of 9. Mean systolic blood pressures were significantly different based on radial pulse strength: strong (129.6), weak (107.5), and absent (85.1). However, when using a binary threshold of 80 mmHg, there were 615 documented instances of hypotension. Within that 615, 55.6% had a strong radial pulse, 29.3% had a weak radial pulse, and 15.1% had an absent radial pulse (P < .001)., Conclusions: Although mean systolic blood pressure was associated with radial pulse quality, when using a binary measurement of hypotension (systolic < 80 mmHg) characterization of the radial pulse was not a reliable indicator of hypotension. Better methods for casualty monitoring must be employed to avoid missing opportunities for intervention., (Published by Oxford University Press on behalf of Association of Military Surgeons of the United States 2020. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Background: Role 1 care represents all aspects of prehospital care on the battlefield. Recent conflicts and military operations conducted on behalf of the Global War on Terrorism have resulted in medical officers (MOs) being used nondoctrinally on combat missions. We are seeking to describe Role 1 trauma care provided by MOs and compare this care to that provided by medics., Methods: This is a secondary analysis of previously described data from the Prehospital Trauma Registry and the Department of Defense Trauma Registry from April 2003 through May 2019. Encounters were categorized by type of care provider (MO or medic). If both were documented, they were categorized as MO; those without either were excluded. Descriptive statistics were used., Results: A total of 826 casualty encounters met inclusion criteria. There were 418 encounters categorized as MO (57 with MO, 361 with MO and medic), and 408 encounters categorized as medic only. The composite injury severity score (median, interquartile range) was higher for casualties treated by the medic cohort (9, 3.5-17) than for the MO cohort (5, 2-9.5; P = .006). There was no difference in survival to discharge between the MO and medic groups (98.6% vs. 95.6%; P = .226). More life-saving interventions were performed by MOs compared to medics. MOs demonstrated a higher rate of vital sign documentation than medics., Conclusion: More than half of casualty encounters in this study listed an MO in the chain of care. The difference in proportion of interventions highlights differences in provider skills, training and equipment, or that interventions were dictated by differences in mechanisms of injury., (2020.)

Introduction: Hemorrhage is the leading cause of preventable death on the battlefield, and hemostasis is particularly challenging to achieve at junctional sites such as the axillary or inguinal regions. Mission-oriented protective posture (MOPP) gear, as worn most recently in Syria to guard against chemical weapons, can make the performance of technical skills more challenging still. The objective of this study was to evaluate how wearing MOPP gear affects the application time of the SAM Medical Junctional Tourniquet (SJT) by U.S. Army combat medics., Materials and Methods: We conducted a prospective, randomized control trial evaluating time for SJT application between participants wearing MOPP versus those not wearing MOPP. Secondary outcomes included SJT application success rate and participant appraisal of SJT application difficulty assessed with five-point Likert items, between groups. Participants placed SJTs on robotic simulation mannequins with a penetrating inguinal injury., Results: In April 2019, we enrolled 49 combat medics. Most participants were male (77.5%), had a median age of 25 (interquartile range 23-28), and in the grade of E4 or less (63.3%). Mean SJT application times in seconds were higher among those wearing MOPP versus those who were not (223.1 versus 167.2; 95% confidence interval for difference in means 5.293, 106.374; P = 0.03). Participants wearing MOPP had a less successful application rate overall, but this difference was not statistically significant (64.3% versus 81.0%, P = 0.34). Compared to participants not wearing MOPP, those wearing MOPP agreed that SJT application was difficult (4 versus 3, P = 0.03), what they were wearing affected SJT application (4 versus 2, P = 0.01), and it was difficult to use their hands during SJT application (4 versus 1, P < 0.001)., Conclusions: Wearing military MOPP gear significantly prolongs the amount of time required for combat medics to apply an SJT on a simulated casualty with a penetrating inguinal injury. This study highlights the importance of incorporating MOPP gear into medical training scenarios to improve skills competency while wearing these protective garments., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2020. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Background: The United States (US) military utilizes combat wound medication packs (CWMP) to provide analgesia and wound prophylaxis in casualties who are still able to fight. We compared characteristics of combat casualties receiving CWMP to those not receiving CWMP. We also describe the proportions of casualties with injury patterns consistent with Tactical Combat Casualty Care (TCCC) guideline indications for CWMP use who received this intervention., Methods: This is a secondary analysis of Department of a Defense Trauma Registry (DODTR) dataset of US military personnel from January 2007 to August 2016. We searched for all subjects with documented use of at least one medication from the CWMP (acetaminophen, meloxicam, moxifloxacin)., Results: Within our dataset, 11,665 casualties were US military Servicemembers. Overall, <1% (84) of our study population received the CWMP. The median age and mechanism of injuries were similar between CWMP nonrecipients versus recipients. Median composite injury scores were higher for nonrecipients than recipients (6 versus 4, P < .001). Proportions of casualties with injury patterns meeting TCCC guideline CWMP indications who received this intervention were low: gunshot wound, <1% (14 of 1805), tourniquet applied, <1% (11 of 1912), major amputation, <1% (5 of 803), and open fracture, <1% (10 of 2425). Based on serious injuries by body region, we had similar findings for the thorax (<1%; 3 of 1122), abdomen (<1%; 1 of 736), and extremities (<1%; 11 of 2699)., Conclusions: Subjects receiving the CWMP were less severely injured compared to those who did not receive this intervention. The CWMP had very infrequent use among those casualties with injury patterns meeting indications specified in the TCCC Guidelines for use of this intervention., (2020.)

Introduction: Airway compromise is the second leading cause of potentially survivable death on the battlefield. Studies show that airway management is a challenge in prehospital combat care with high error and missed opportunity rates. Lacking is user information on the perceived reasons for the challenges. The US military uses several performance improvement and field feedback systems to solicit feedback regarding deployed experiences. We seek to review feedback and after-action reviews (AARs) from end-users with specific regard to airway challenges noted., Methods: We queried the Center for Army Lessons Learned (CALL), the Army Medical Department Lessons Learned (AMEDDLL), and the Joint Lessons Learned Information System (JLLIS).Our queries comprised a series of search terms with a focus on airway management. Three military emergency medicine expert reviewers performed the primary analysis for lessons learned specific to deployment and predeployment training lessons learned. Upon narrowing the scope of entries to those relevant to deployment and predeployment training, a panel of eight experts performed reviews. The varied nature of the sources lent itself to an unstructured qualitative approach with results tabulated into thematic categories., Results: Our initial search yielded 611 nonduplicate entries. The primary reviewers then analyzed these entries to determine relevance to the project-this resulted in 70 deployment- based lessons learned and four training-based lessons learned. The panel of eight experts then reviewed the 74 lessons learned. We categorized 37 AARs as equipment challenges/malfunctions, 28 as training/education challenges, and 9 as other. Several lessons learned specifically stated that units failed to prioritize medic training; multiple comments suggested that units should consider sending their medics to civilian training centers. Other comments highlighted equipment shortages and equipment malfunctions specific to certain mission types (e.g., pediatric casualties, extreme weather)., Conclusions: In this review of military lessons learned systems, most of the feedback referenced equipment malfunctions and gaps in initial and maintenance training.This review of AARs provides guidance for targeted research efforts based the needs of the end-users., (2020.)

Background: Mounting evidence suggests hyperoxia therapy may be harmful. We describe injury characteristics and survival outcomes for pediatric trauma casualties in Iraq and Afghanistan, stratified by partial pressure of arterial oxygen (PaO2). Secondarily, we performed subgroup analyses for severe traumatic brain injury (TBI) and massive transfusion of blood products (MT)., Methods: We utilized Department of Defense Trauma Registry data. We included subjects <18 years. We excluded subjects without an arterial blood gas (ABG). We stratified subjects as hyperoxemia (PaO2 100-300 mmHg) and extreme hyperoxemia (PaO2 >300 mmHg)., Results: January 2007-January 2016, 3439 pediatric encounters were in the database. Of those, 1323 had an ABG, with 291 (22%) demonstrating hyperoxemia and 43 (3.3%) extreme hyperoxemia. The median age was 8, most were male (76%) in Afghanistan (69%), and injured by explosive (42%). There were no significant differences in survival between subjects with no hyperoxemia, hyperoxemia, and extreme hyperoxemia (92% vs 87% vs 86%; p = 0.078). Also, there were no significant differences in survival between groups among TBI and MT subjects, and there were no increased odds of survival between groups on multivariable regression analyses., Conclusions: Hyperoxemia was common among hospitalized, wartime pediatric trauma casualties in Iraq and Afghanistan that underwent ABG analysis. Survival to hospital discharge rates were not significantly different between subjects with hyperoxemia and subjects without hyperoxemia., Competing Interests: Declaration of Competing Interest We have no conflicts to report., (Published by Elsevier Inc.)

Introduction: Airway obstruction is the second leading cause of preventable death on the battlefield. Most airway obstruction occurs secondary to traumatic disruptions of the airway anatomical structures. However, casualties may require airway interventions for other indications (e.g., depressed mental status). We describe casualties undergoing airway intervention in the prehospital, combat setting without apparent upper airway trauma., Materials and Methods: We used a series of emergency department procedure codes to identify patients within the Department of Defense Trauma Registry (DODTR) from January 2007 to August 2016. This is a subgroup analysis of those patients with a documented prehospital airway intervention and no apparent airway trauma as defined by abbreviated injury scale of 0 for body regions 1 (head/neck) and 2 (face)., Results: Our predefined search codes captured 28222 DODTR subjects of whom 409 (1.4%) met criteria for study inclusion. Subjects included members of host nation forces (34%) and civilians (30%). Most subjects sustained injuries in Afghanistan (82%). Explosive (57%) and gunshot wounds (36%) were the most frequent mechanisms of injury. Median injury severity scores were 17. The most common anatomical locations of injuries for included subjects included extremities (53%) and thorax (29%). A majority of subjects underwent intubation (89%); comparatively few casualties underwent placement of a nasopharyngeal airway (2%) or supraglottic airway (2%). The proportion of subjects surviving to hospital discharge was 80% and was highest among subjects undergoing intubation (82%)., Conclusions: In this subgroup analysis of casualties without apparent upper airway trauma, survival rates were lower when compared to our previous report. Higher quality data are necessary to better understand the resuscitation needs of this critically ill subset of combat casualties., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2019.)

Background: Traumatic injuries were the most common reason for pediatric admission to military hospitals during the recent wars in the Middle East. We describe injury characteristics and prehospital interventions performed on wartime pediatric trauma casualties in Afghanistan and Iraq, stratified by medical evacuation platform. Methods: We queried the Department of Defense Trauma Registry (DODTR) for all pediatric (age < 18 years) encounters from January 2007 to January 2016. The DODTR is the data repository for all trauma-related injuries managed by deployed US military medical treatment facilities with surgical capabilities. We requested all documented prehospital care, which may have been delivered anywhere from the point-of-injury until a fixed-facility with surgical capabilities. We stratified subjects according to Centers for Disease Control age groupings: <1 year, 1-4 years, 5-9 years, 10-14 years, and 15-17 years. Results: Of the 3,493 pediatric encounters in the DODTR, 1,004 underwent military evacuation from the point of injury: 911 (90.7%) by standard medical evacuation platforms and 93 (9.3%) by nonstandard, improvised evacuation assets. Six hundred seventy-five of the 1004 pediatric trauma casualties were between 5 and 14 years of age. Over 75% were male, over 80% were in Afghanistan, and most were injured by explosives. Across all age groups, serious injuries to the head/neck and extremities were most common. Subjects transported by standard evacuation platforms underwent tourniquet application (12.2% vs 5.3%, p  < 0.05) and intraosseous access (12.2% vs 4.3%; p  = 0.02) more frequently than those on nonstandard platforms. Casualties evacuated by nonstandard platforms underwent airway adjunct emplacement more frequently those on standard evacuation assets (3.2% vs 0.3%; p  = 0.01). IV access and opiate administration were the most commonly performed interventions on both standard and nonstandard assets. Subject survival to hospital discharge was 88.1% on standard platforms and 89.2% on nonstandard platforms ( p  = 0.75). Conclusions: Approximately 30% of pediatric trauma casualties in Afghanistan and Iraq underwent medical evacuation from the point of injury directly to a military treatment facility with surgical capabilities. Most of those children did not undergo the prehospital interventions studied. Future investigations evaluating pediatric medical evacuation and prehospital care, medical staffing, pediatric-specific training, and equipping of pediatric-specific materials may be beneficial.

Introduction: Tactical Combat Casualty Care (TCCC) recommends life-saving interventions; however, these interventions can only be implemented if military prehospital providers carry the necessary equipment to the injured casualty. Combat medics primarily use aid bags to transport medical materiels forward on the battlefield. We seek to assess combat medic materiel preparedness to employ TCCC-recommended interventions by inventorying active duty, combat medic aid bags., Methods: We sought combat medics organic to combat arms units stationed at Joint Base Lewis McChord. Medics volunteered to complete a demographic worksheet and have the contents of their aid bag photographed and inventoried. We spoke with medic unit leadership prior to their participation and asked that the medics bring their aid bags in the way they would pack for a combat mission. We categorized medic aid bag contents in the following manner: (1) hemorrhage control; (2) airway management; (3) pneumothorax treatment, or (4) volume resuscitation. We compared the items found in the aid bags against the contemporary TCCC guidelines., Results: In January 2019, we prospectively inventoried 44 combat medic aid bags. Most of the medics were male (86%), in the grade of E4 (64%), and had no deployment experience (64%). More medics carried a commercial aid bag (55%) than used the standard issue M9 medical bag (45%). Overall, the most frequently carried medical device was an NPA (93%). Overall, 91% of medics carried at least one limb tourniquet, 2% carried a junctional tourniquet, 31% carried a supraglottic airway (SGA), 64% carried a cricothyrotomy setup/kit, 75% carried a chest seal, and 75% carried intravenous (IV) fluid. The most commonly stocked limb tourniquet was the C-A-T (88%), the airway kit was the H&H cricothyrotomy kit (38%), the chest injury set were prepackaged needle decompression kits (81%), and normal saline was the most frequently carried fluid (47%). Most medics carried a heating blanket (54%)., Conclusions: Most medics carried materiels that address the common causes of preventable death on the battlefield. However, most materiels stowed in aid bags were not TCCC-preferred items. Moreover, there was a small subset of medics who were not prepared to handle the major causes of death on the battlefield based on the current state of their aid bag., (2020.)

Background: Infectious complications of war wounds are a significant source of mortality and morbidity. Tactical Combat Casualty Care (TCCC) guidelines recommend prehospital moxifloxacin, ertapenem, or cefotetan for "all open combat wounds." We describe the prehospital administration of antibiotics to pediatric trauma patients., Methods: We queried the Department of Defense Trauma Registry for all pediatric subjects admitted to United States and Coalition fixed-facility hospitals in Iraq and Afghanistan from January 2007 to January 2016., Results: During this time, there were 3,439 pediatric encounters which represented 8.0% of all admissions. Prehospital providers administered a total of 216 antibiotic doses to 210 subjects. Older children received antibiotics more frequently than younger children, were more likely to be male, located in Afghanistan, and injured by explosive with the majority surviving to hospital discharge. Cefazolin and ceftriaxone were the most frequently utilized antibiotics., Conclusions: The most frequently administered antibiotics were cephalosporins. TCCC recommended agents for adult prehospital wound prophylaxis were infrequently administered to pediatric casualties. Administration rates of pediatric prehospital wound prophylaxis may be improved with pediatric-specific TCCC guidelines recommending cephalosporins as first-line agents, fielding of a TCCC-oriented Broselow tape, and training prehospital providers on administration of antimicrobials., (© Association of Military Surgeons of the United States 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Point-of-injury extended focused assessment with sonography in trauma (eFAST) may identify life-threatening torso hemorrhage and expedite casualty evacuation. The purpose of this study was to compare combat medic eFAST performance between the novel and conventional ultrasound (US) transducers., Methods: We conducted a randomized crossover trial. Medic participants, previously naïve to US, were randomized to the type of transducer first utilized. The primary outcome was eFAST completion time in seconds. Secondary outcomes included diagnostic accuracy, technical adequacy, and transducer ease-of-use rating., Results: Forty medics performed 160 eFASTs. We found a statistically significant difference in eFAST completion times in favor of conventional transducers (304 vs. 358 s; P = 0.03). There was no statistically significant difference between the conventional and novel transducers in terms of diagnostic accuracy (97.7% vs. 96.0%; P = 0.25) and technical adequacy (65% vs. 72.5%; P = 0.11). Median transducer ease-of-use rating (Likert 1-5 scale) was statistically significant in favor of the conventional transducers (5 vs. 4; P = < 0.001)., Conclusions: Extended focused assessment with sonography in trauma exam times was faster with the conventional transducers. Combat medics performed diagnostically accurate eFASTs with both transducer types in a simulated aid station setting after a brief training intervention. Conventional transducers were rated higher for ease-of-use., (© Association of Military Surgeons of the United States 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Oxygen supplementation is frequently used in critically injured trauma casualties in the combat setting. Oxygen supplies in the deployed setting are limited so excessive use of oxygen may unnecessarily consume this limited resource. We describe the incidence of supraphysiologic oxygenation (hyperoxia) within casualties in the Department of Defense Trauma Registry (DoDTR)., Methods: This is a subanalysis of previously published data from the DoDTR - we isolated casualties with a documented arterial blood gas (ABG) and categorized hyperoxia as an arterial oxygen >100 mmHg and extreme hyperoxia > 300 mmHg (a subset of hyperoxia). We defined serious injuries as those with an Abbreviated Injury Score (AIS) of 3 or greater. We defined a probable moderate traumatic brain injury of those with an AIS of 3 or greater for the head region and at least one Glasgow Coma Scale at 8 or less., Results: Our initial search yielded 28,222 casualties, of which 10,969 had at least one ABG available. Within the 10,969, the proportion of casualties experiencing hyperoxia in this population was 20.6% (2,269) with a subset of 4.1% (452) meeting criteria for extreme hyperoxia. Among those with hyperoxia, the median age was 25 years (IQR 21-30), most were male (96.8%), most frequently US forces (41.4%), injured in Afghanistan (68.3%), injured by explosive (61.1%), with moderate injury scores (median 17, IQR 10-26), and most (93.8%) survived to hospital discharge. A total of 17.8% (1,954) of the casualties underwent endotracheal intubation: 27.5% (538 of 1,954) prior to emergency department (ED) arrival and 72.5% (1,416 of 1,954) within the ED. Among those intubated in the prehospital setting, upon ED arrival 35.1% (189) were hyperoxic, and a subset of 5.6% (30) that were extremely hyperoxic. Among those intubated in the ED, 35.4% (502) were hyperoxic, 7.9% (112) were extremely hyperoxic. Within the 1,277 with a probable TBI, 44.2% (565) experienced hyperoxia and 9.5% (122) met criteria for extreme hyperoxia., Conclusions: In our dataset, more than 1 in 5 casualties overall had documented hyperoxia on ABG measurement, 1 in 3 intubated casualties, and almost 1 in 2 TBI casualties. With limited oxygen supplies in theater and logistical challenges with oxygen resupply, efforts to avoid unnecessary oxygen supplementation may have material impact on preserving this scarce resource and avoid potential detrimental clinical effects from supraphysiologic oxygen concentrations., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2019.)

Background: Hemorrhage is the leading cause of potentially survivable deaths in combat. Previous research demonstrated that tranexamic acid (TXA) administration decreased mortality among casualties. For casualties expected to receive a transfusion, the Committee on Tactical Combat Casualty Care (TCCC) recommends TXA. Despite this, the use and adherence of TXA in the military prehospital combat setting, in accordance with TCCC guidelines, is low., Objectives: We sought to analyze TXA administration and use among combat casualties reasonably expected to require blood transfusion, casualties with tourniquet placement, amputations, and gunshot wounds., Methods: Based on TCCC guidelines, we measured proportions of patients receiving prehospital TXA: casualties undergoing tourniquet placement, casualties sustaining amputation proximal to the phalanges, patients sustaining gunshot wounds, and patients receiving ≥10 units of blood products within 24 h of injury. Univariable and multivariable analyses were also completed., Results: Within our dataset, 255 subjects received TXA. Four thousand seventy-one subjects had a tourniquet placed, of whom 135 (3.3%) received prehospital TXA; 1899 subjects had an amputation proximal to the digit with 106 (5.6%) receiving prehospital TXA; and 6660 subjects had a gunshot wound with 88 (1.3%) receiving prehospital TXA. Of 4246 subjects who received ≥10 units of blood products within the first 24 h, 177 (4.2%) received prehospital TXA., Conclusions: We identified low TXA administration despite TCCC recommendations. Future studies should seek to both identify reasons for limited TXA administration and methods to increase future utilization., (Published by Elsevier Inc.)

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.

Background: Airway compromise is the second leading cause of preventable death on the battlefield. Unlike a cricothyrotomy, supraglottic airway (SGA) placement does not require an incision and is less technically challenging. We compare survival of causalities undergoing cricothyrotomy versus SGA placement., Methods: We used a series of emergency department (ED) procedure codes to search within the Department of Defense Trauma Registry (DoDTR) from January 2007 to August 2016. This is a subanalysis of that dataset., Results: During the study period, 194 casualties had a documented cricothyrotomy and 22 had a documented SGA as the sole airway intervention. The two groups had similar proportions of explosive injuries (57.7% versus 63.6%, p = .328), similar composite injury severity scores (25 versus 27.5, p = .168), and similar AIS for the head, face, extremities, and external body regions. The cricothyrotomy group had lower AIS for the thorax (0 versus 3, p = .019) a trend toward lower AIS for the abdomen (0 versus 0, p = .077), more serious injuries to the head (67.5% versus 45.5%, p = .039), and similar rates of serious injuries to the face (4.6% versus 4.6%, p = .984). Glasgow Coma Scale (GCS) scores were similar upon arrival to the ED (3 versus 3, p = .467) as were the proportion of patients surviving to discharge (45.4% versus 40.9%, p = .691). On repeated multivariable analyses, the odds ratios (ORs) for survival were not significantly different between the two groups., Conclusion: We found no difference in short-term outcomes between combat casualties who received an SGA vs cricothyrotomy. Military prehospital personnel rarely used either advanced airway intervention during the recent conflicts in Afghanistan and Iraq., (2019.)

Introduction: The recent conflicts in Iraq and Afghanistan entail an asymmetric battlefield without clearly defined forward lines of troops as seen in previous wars. Accordingly, the United States military medical services have increasingly adopted casualty evacuation (CASEVAC) platforms. We describe CASEVAC events reported within the Department of Defense Trauma Registry (DODTR)., Materials and Methods: This is a secondary analysis of previously published data from two datasets spanning from 2007 through 2017. We isolated casualties within our dataset that had a documented evacuation method from the point-of-injury other than dedicated medical evacuation platforms (e.g., MEDEVAC, etc.)., Results: During OPERATION IRAQI FREEDOM, three casualties underwent CASEVAC. The median age was 30 and all were male. Most sustained injuries from explosives (67%) and the median composite injury scores were low (10). The most frequent seriously injured body region was the thorax (67%). All survived to hospital discharge. During operations in Afghanistan (OPERATION ENDURING FREEDOM, OPERATION FREEDOMS SENTINEL, OPERATION NEW DAWN), 248 casualties underwent CASEVAC. The median age was 28 and most (96%) were male. Most sustained injuries from explosives (58%) and the median injury score was low (9). The most frequent seriously injured body region was the extremities (24%). Most (97%) survived to hospital discharge. During OPERATION INHERENT RESOLVE, 247 casualties underwent CASEVAC. The median age was 21 and most (96%) were male. The majority sustained injuries from explosives (61%) and the median injury score was low (9). The most frequent seriously injury body region was the extremities (27%). Most survived to hospital discharge (94%)., Conclusions: In our dataset, CASEVAC events most frequently involved US military personnel service members with most surviving to hospital discharge. Developing new terminology that distinguishes different types of CASEVAC would allow for more accurate future analyses of casualty evacuation and outcomes - such as those transports that are truly in a non-medical versus the various medical platforms that do not fall with into the confines of the MEDEVAC platforms., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2019.)

Background: Airway compromise is the second leading cause of preventable death on the battlefield. Unlike a cricothyrotomy, supraglottic airway (SGA) placement does not require an incision and is less technically challenging. We compare the survival of causalities undergoing cricothyrotomy versus SGA placement., Methods: We used a series of emergency department (ED) procedure codes to search within the Department of Defense Trauma Registry (DODTR) from January 2007 to August 2016. This is a subanalysis of that data set., Results: During the study period, 194 casualties had a documented cricothyrotomy and 22 had a documented SGA as the sole airway intervention. The two groups had similar proportions of explosive injuries (57.7% versus 63.6%, p = .328), similar composite injury severity scores (25 versus 27.5, p = .168), and similar AIS for the head, face, extremities, and external body regions. The cricothyrotomy group had lower AIS for the thorax (0 versus 3, p = .019), a trend toward lower AIS for the abdomen (0 versus 0, p = .077), more serious injuries to the head (67.5% versus 45.5%, p = .039), and similar rates of serious injuries to the face (4.6% versus 4.6%, p = .984). Glasgow Coma Scale (GCS) scores were similar on arrival to the ED (3 versus 3, p = .467) as were the proportion of patients surviving to discharge (45.4% versus 40.9%, p = .691). On repeated multivariable analyses, the odds ratios for survival were not significantly different between the two groups., Conclusions: We found no difference in short-term outcomes between combat casualties who received an SGA vs those who received a cricothyrotomy. Military prehospital personnel rarely used either advanced airway intervention during the recent conflicts in Afghanistan and Iraq., (2019.)

Introduction: U.S. military forces were redeployed in 2014 in support of Operation Inherent Resolve (OIR), operating in an austere theater without the benefit of an established medical system. We seek to describe the prehospital and hospital-based care delivered in this medically immature, non-doctrinal theater., Materials and Methods: We queried the Department of Defense Trauma Registry (DODTR) for all encounters associated with OIR from August 2014 through June 2017. We sought all available prehospital and hospital-based data., Results: There were a total of 826 adults that met inclusion; 816 were from Iraq and the remaining 10 were from Syria. The median age was 21 years and the most frequent mechanism of injury was explosives (47.7%). Median composite injury severity scores were low (9, IQR 2.75-14) and the most frequent seriously injured body region was the extremities (23.0%). Most subjects (94.9%) survived to hospital discharge. Open fractures were the most frequent major injury (26.0%). In the prehospital setting, opioids were the most frequently administered medication (9.3%) and warming blanket application (48.7%) and intravenous line placement (24.8%) were the most frequent interventions. In the emergency department, Focused Assessment with Sonography in Trauma exams (64.3%) was the most frequently performed study and endotracheal intubations were the most frequent (29.9%) procedure. In the operating room, the most frequently performed procedure was exploratory laparotomy (12.3%)., Conclusions: Host nation military males injured by explosion comprised the majority of casualties. Open fracture was the most common major injury. Hence, future research should focus upon the unique challenges of delivering care to members of partner forces with particular focus upon interventions to optimize outcomes among patients sustaining open fractures., (© Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2018.)

Introduction: The 2010-2011 withdrawal from Iraq included the closure of all fixed-facility military medical resources. Operation INHERENT RESOLVE, the United States-led counter-terrorism mission in Iraq and Syria, subsequently commenced in 2014. With increasing combat operations, the 28th Combat Support Hospital deployed to Iraq to support that mission as a limited footprint unit prototyped after the new modular Army Field Hospital. We describe the non-battle utilization of the emergency medical treatment section., Methods: We prospectively collected data for this project as part of a performance improvement initiative to track healthcare utilization to guide emergency medical treatment section staffing. The project took place at a combat support hospital near Baghdad, Iraq from July 2016 through January 2017., Results: During this time, the emergency department (ED) averaged 3.5 visits per day totaling 675 non-battle encounters. Most (84.6%) were U.S. military personnel with a median age of 32 (IQR 26-38). The most common procedure performed was point-of-care ultrasound (n = 33). Most patients (96.9%) underwent discharge from the ED. Of the 21 subjects admitted, 6 were for surgical intervention and the remaining for medical or observational indications. The most common chief complaints were musculoskeletal (31.1%, n = 210), respiratory (15.3%, n = 103), and dermatologic (12.0%, n = 81)., Conclusions: Non-battle injuries and illnesses were the predominant reason for ED utilization. Most subjects were discharged back to duty with relatively low-resource utilization. Few visits required procedural interventions., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2018.)

Introduction: Hemorrhage is the leading cause of potentially preventable death on the battlefield. Hypotension in the setting of trauma portends a higher rate of mortality. We describe the interventions for trauma-related hypotension performed in the prehospital combat setting in accordance with Tactical Combat Casualty Care (TCCC) guidelines., Materials and Methods: We searched the Prehospital Trauma Registry for casualties from January 2013 to September 2014. Within that group, we searched for all casualties with documented hypotension by either measured systolic blood pressure ≤90 mmHg or a weak or absent radial pulse documented by the prehospital provider. We used descriptive statistics to analyze the interventions performed in our study sample., Results: Of the 705 casualties available for query, 134 (19.0%) casualties with documented hypotension met inclusion criteria. Most casualties with hypotension had an alert mental status (70.1%), had a medical officer in their chain of care (59.0%), were Afghan (64.2%), and evacuated on an urgent status (78.4%). Explosives were the most frequent mechanism of injury (50.7%). There were 42 fluid administrations documented on 33 (24.6%) casualties. The most common fluid administered was normal saline (52.4%) followed by hetastarch solution (33.3%). There was one documented use of a fluid warmer in this cohort. One subject received four units of packed red blood cells. No other casualties had documented blood product administration. There were no documented administrations of PlasmaLyte. There were four casualties that received lactated Ringer's., Conclusion: Most casualties with documented hypotension after trauma in the Prehospital Trauma Registry did not receive prehospital blood or fluid intervention. Of the interventions performed, most did not match with contemporary TCCC guidelines., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2018.)

Background: Peripheral intravenous (IV) cannulation is often difficult to obtain in a patient with hemorrhagic shock, delaying the appropriate resuscitation of critically ill patients. Intraosseous (IO) access is an alternative method. To date, few data exist on use of this procedure by ground forces in Afghanistan. Here, we compare patient characteristics and concomitant interventions among patients undergoing IO access versus those undergoing IV access only., Methods: We obtained data from the Prehospital Trauma Registry (PHTR). When possible, patients were linked to the Department of Defense Trauma Registry for outcome data. To develop the cohorts, we searched for all patients with documented IO or IV access placement. Those with both IO and IV access documented were placed in the IO group., Results: Of the 705 available patients in the PHTR, we identified 55 patients (7.8% of the population) in the IO group and 432 (61.3%) in the IV group. Among patients with documentation of access location, the most common location was the tibia (64.3%; n = 18). Compared with patients with IV access, those who underwent IO access had higher urgent evacuation rates (90.9% versus 72.4%; p = .01) and air evacuation rates (58.2% versus 14.8%; p < .01). The IO cohort had significantly higher rates of interventions for hypothermia, chest seals, chest tubes, needle decompressions, and tourniquets, but a significantly lower rate of analgesic administration (ρ ≤ .05)., Conclusion: Within the registry, IO placement was relatively low (<10%) and used in casualties who received several other life-saving interventions at a higher rate than casualties who had IV access. Incidentally, lower proportions of analgesia administration were detected in the IO group compared with the IV group, despite higher intervention rates., (2019.)

Background: Tactical Combat Casualty Care (TCCC) guidelines regarding prehospital analgesia agents have evolved. The guidelines stopped recommending intramuscular (IM) morphine in 1996, recommending only intravenous (IV) routes. In 2006, the guidelines recommended oral transmucosal fentanyl citrate (OTFC), and in 2012 it added ketamine via all routes. It remains unclear to what extent prehospital analgesia administered on the battlefield adheres to these guidelines. We seek to describe trends in analgesia administration patterns on the battlefield during 2007-2016., Methods: This is a secondary analysis of a Department of Defense Trauma Registry data set from January 2007 to August 2016. Within that group, we searched for subjects who received IM morphine, IV morphine, OTFC, parenteral fentanyl, or ketamine (all routes)., Results: Our predefined ED search codes captured 28,222 subjects during the study period. Of these, 594 (2.1%) received IM morphine; 3,765 (13.3%) received IV morphine; 589 (2.1%) received OTFC; and 1,510 (5.4%) subjects received ketamine. Annual rates of administration of IM morphine were relatively stable during the study period, while those for OTFC and ketamine generally trended upward starting in 2012. In particular, the proportion of subjects receiving ketamine rose from 3.9% (n = 995/25,618) during the study period preceding its addition to the TCCC guidelines (2007 to 2012) to 19.8% thereafter (2013-2016, n = 515/2,604, p < 0.001)., Conclusions: During the study period, rates of prehospital administration of IM morphine remained relatively stable while those for OTFC and ketamine both rose. These findings suggest that TCCC guidelines recommending the use of these agents had a material impact on prehospital analgesia patterns.

Introduction: The United States (US) military has expanded its area of operations into Africa. This medically immature theater is spread across a large region where prolonged field care (PFC) events are likely to occur. We describe trauma cases reported in the Africa Command (AFRICOM) area of operations to date within the Department of Defense Trauma Registry (DODTR)., Methods: We queried the DODTR for all subjects evacuated from the AFRICOM area of operations from January 2002 to June 2017., Results: There were 49 subjects in the registry during our time frame from AFRICOM. Most of the evacuations came from Djibouti (53%). The median age was 29 years, most evacuees being male (92%). Non-battle injuries accounted for most of the injuries (82%), and most were US military (90%). All battle injuries were gunshot wounds (GSW). Composite injury scores were low (median 4, IQR 4-9.5). All subjects survived to hospital discharge. GSWs (22%) and sports injuries (24%) accounted for most evacuations. Serious injuries most frequently involved the extremities (18%) and the thorax (12%). The most frequent major injuries were open fractures (22%) and abdominal injuries (10%). The most frequent facility-based interventions performed were wound debridement (29%) and fracture/joint dislocation reduction (22%)., Discussion: Based on this dataset, most of the injuries from AFRICOM were non-battle injuries. All battle injuries were GSWs. Our study highlights the differences in casualty care needs in this region which contrast the primary explosive-based injuries seen within United States Central Command (CENTCOM) operations. The limitations of this dataset highlight the potential value of a Joint Trauma Service (JTS) data collection mandate and resource support for units within this region to facilitate targeted improvements in medical care.

Background: During the past 17 years of conflict the deployed US military health care system has found new and innovative ways to reduce combat mortality down to the lowest case fatality rate in US history. There is currently a data dearth of emergency department (ED) care delivered in this setting. We seek to describe ED interventions in this setting., Methods: We used a series of ED procedure codes to identify subjects within the Department of Defense Trauma Registry from January 2007 to August 2016., Results: During this time, 28,222 met inclusion criteria. The median age of causalities in this dataset was 25 years and most (96.9%) were male, US military (41.3%), and part of Operation Enduring Freedom (66.9%). The majority survived to hospital discharge (95.5%). Most subjects sustained injuries by explosives (55.3%) and gunshot wound (GSW). The majority of subjects had an injury severity score that was considered minor (74.1%), while the preponderance of critically injured casualties sustained injuries by explosive (0.7%). Based on AIS, the most frequently seriously injured body region was the extremities (23.9%). The bulk of administered blood products were packed red blood cells (PRBC, 26.4%). Endotracheal intubation was the most commonly performed critical procedure (11.9%). X-ray (79.9%) was the most frequently performed imaging study., Conclusions: US military personnel comprised the largest proportion of combat casualties and most were injured by explosive. Within this dataset, ED providers most frequently performed endotracheal intubation, administered blood products, and obtained diagnostic imaging studies., (Published by Elsevier Inc.)

Objectives: Airway failures are the second leading cause of potentially preventable death on the battlefield. Improvements in airway management depend on identifying current challenges. We sought to build on previously reported data on prehospital, combat airway management., Methods: We used a series of emergency department procedure codes to identify patients within the Department of Defense Trauma Registry from January 2007 to August 2016. This is a subanalysis of those with a documented prehospital airway intervention., Results: Of the 28,222 patients in our dataset, 1379 (4.9%) had a documented prehospital airway intervention. Airway devices consisted of 49 airway adjuncts (17 nasopharyngeal airways, 2 oropharyngeal airways, remainder listed as unspecified), 230 cricothyrotomies, 1117 endotracheal intubations, and 27 supraglottic airways. Patients undergoing airway intervention were mostly members of the US military (42.2%). Compared with those without airway intervention, they were slightly younger (median 24 vs 25 years, P < 0.001), more frequently injured by explosives (57.7% vs 55.2%, P < 0.001) and gunshot wound (28.7% vs 23.3%, P < 0.001), with higher injury severity scores (composite and by body region) except the superficial body region, and less likely to survive to discharge (73.5% vs 96.6%, P < 0.001). Vecuronium (35.4%) and midazolam (27.9%) were the most frequently used paralytic and sedative, respectively., Conclusions: Patients undergoing airway intervention were most frequently injured by explosive or gunshot wound. Intubations and cricothyrotomies were the most frequent airway interventions performed. Patients undergoing interventions were more critically injured, with higher mortality rates. Further research is needed to determine methods to reduce mortality in this critically injured population.

Background: Junctional hemorrhage surpassed extremity hemorrhage as the leading cause of preventable death after the resurgence of limb tourniquets during the recent conflicts in Afghanistan and Iraq. Junctional tourniquets (JTQs) were developed in response to this injury pattern. Published data for JTQ efficacy are limited and do not incorporate nonmedical, military first responders. We compared the time for effective placement and scores for device satisfaction between two different JTQs, stratified by combat lifesaver (CLS) and combat medics., Methods: We performed a prospective, randomized, crossover trial utilizing the SAM® Medical Junctional Tourniquet (SJT) and Junctional Emergency Treatment Tool (JETT™). Investigators simple randomized CLS and combat medics to SJT or JETT for their first JTQ application on mannequins with penetrating inguinal injuries. Then, participants immediately placed the other JTQ on another casualty with the same injury. The primary outcome measured was time of successful application. Success was defined as proper JTQ placement and a pressure reading of at least 180 mmHg. We compared outcomes between CLS and combat medics. Unsuccessful JTQ applications were excluded from the comparative analysis., Results: From June 2015 to August 2015, a total of 227 personnel (133 CLS and 94 combat medics) at Fort Hood, Texas, USA volunteered to participate in the study. Twenty-eight percent (38 of 133) of CLS and 40% (38 of 94) of combat medics placed both JTQs successfully, for a total of 152 applications (76 SJTs and 76 JETTs). We found a significant difference between applications of the JETT between the CLS and combat medics (92.0 ± 37.7 s versus 70.5 ± 20.5 s, P = 0.004). No other subgroup analyses, whether by device or user, demonstrated a significant difference in application time. Both groups preferred the SJT over the JETT. CLS disagreed with combat medics that the JETT could be easily applied by one person (median 3.0 [2.0, 4.0] versus median 4.0 [3.0, 5.0]; P = 0.006)., Conclusion: Overall, success rates for both the SJT and JETT were low. Improved training is needed to increase successful application of junctional tourniquets before widespread implementation. Combat lifesavers and combat medics prefer the SJT over the JETT.

Background: Previous studies have evaluated prehospital analgesia during combat operations in Iraq and Afghanistan, but were limited to the adult population. However, a significant portion of the casualties of those conflicts were children. We describe the prehospital analgesia administered to wartime pediatric trauma patients., Methods: We queried the Department of Defense Trauma Registry (DODTR) for all pediatric patients (<18 years of age) admitted to United States and Coalition fixed-facility hospitals in Iraq and Afghanistan from January 2007 to January 2016. We divided pediatric patients into 2 groups: those that had documentation of receipt of analgesic drugs in the prehospital setting (n = 618) and those who had not received analgesia before reaching a fixed-facility (n = 2,821). For characterization of drug administration, we grouped patients into those receiving acetaminophen, NSAID, fentanyl, ketamine, morphine, or other analgesics (e.g., hydromorphone, tramadol, etc.)., Results: During the study period, there were 3,439 pediatric encounters with documentation of 703 instances of analgesia administrations to 618 patients (17.9% of total pediatric encounters). Of the subjects receiving analgesic agents, 46.2% (n = 325) received morphine, 30.4% (n = 214) received fentanyl, 17.4% (n = 122) received ketamine, 1.8% (n = 13) received acetaminophen, and 2.8% (n = 20) received a non-steroidal anti-inflammatory drug. The remaining 9 administrations consisted of methoxyflourane (1), nalbuphine (2), hydromorphone (3), and tramadol (3). An injury severity score (ISS) >15 increased the odds of receiving an analgesic agent (OR 1.26, 95% CI 1.02-1.56). Additionally, there was an association between analgesia administration and the following prehospital interventions: wound dressing, tourniquet, intravenous (IV) line placement, intraosseous line placement, IV fluids, intubation, and external warming., Conclusions: Overall, a low proportion of pediatric trauma subjects within this population received analgesia in the prehospital environment. The most common analgesic medication administered was morphine. Those receiving analgesic agents had more severe injuries and higher rates of concomitant interventions. These results highlight the potential need for Tactical Combat Casualty Care guidelines specifically providing recommendations for analgesia administration among pediatric patients.

Background: Military hospital healthcare providers treated children during the recent conflicts in Afghanistan and Iraq. Compared to adults, pediatric patients present unique challenges during trauma resuscitations and have notably been discussed in few research reports. We seek to describe ED interventions performed on pediatric trauma patients in Iraq and Afghanistan., Methods: We queried the Department of Defense Trauma Registry (DODTR) for all pediatric patients in Iraq and Afghanistan from January 2007 to January 2016. Subjects were grouped based on Centers for Disease Control age categories. We used descriptive statistics., Results: During this period, there were 3388 pediatric encounters that arrived at the ED with signs of life or on-going interventions. Most subjects were male (77.2%), located in Afghanistan (67.9%), injured by explosive (43.2%), and admitted to an intensive care unit (57.8%). Most of those arriving to the ED alive or with on-going interventions survived to hospital discharge (91.6%). The most frequently encountered age group was 5-9years (33.3%) followed by 10-14years (31.5%). The most common interventions were vascular access (86.6%), fluid administration (85.0%), and external warming (44.6%). Intubation was the most frequent airway intervention (18.2%). Packed red blood cells were the most frequently administered blood product (33.8% of subjects)., Conclusions: Pediatric subjects accounted for a notable portion of care delivered in theater emergency departments during the study period. Vascular access and fluid administration were the most frequently performed interventions. Pediatric-specific training is needed as a part of deployment medicine operations., (Copyright © 2018. Published by Elsevier Inc.)

Background: United States (US) and coalition military medical units deployed to combat zones frequently encounter pediatric trauma patients. Pediatric patients may present unique challenges due to their anatomical and physiological characteristics and most military prehospital providers lack pediatric-specific training. A minimal amount of data exists to illuminate the prehospital care of pediatric patients in this environment. We describe the prehospital care of pediatric trauma patients in Iraq and Afghanistan., Methods: We queried the Department of Defense Trauma Registry (DODTR) for all pediatric subjects admitted to US and Coalition fixed-facility hospitals in Iraq and Afghanistan from January 2007 to January 2016. Subjects were grouped by age: <1, 1-4, 5-9, 10-14, and 15-17 years. We focused our analysis on interventions related to trauma resuscitation., Results: Of 42,790 encounters in the DODTR during the study period, 3,439 (8.0%) were aged <18 years. Most subjects were in the 5-9 age group (33.1%), male (77.1%), located in Afghanistan (67.8%), injured by explosives (43.1%). Most subjects survived to hospital discharge (90.2%). The most frequently performed interventions were tourniquet placement (6.6%), intubation (6.1%), supplemental oxygen (11.7%), IV access (24.8%), IV fluids (13.3%), IO access (5.1%), and hypothermia prevention (44.5%). The most frequently administered medications were antibiotics (6.2%) and opioids (15.0%). Most procedural and medication interventions occurred in subjects injured by explosives (43.1%) and gunshot wounds (22.1%)., Conclusions: Pediatric subjects comprised over 1 in 13 casualties treated in the joint theaters with the majority injured by explosives. Vascular access and hypothermia prevention interventions were the most frequently performed procedures.

Introduction: Hemorrhage is the leading cause of death on the battlefield. Development of chitosan- and kaolin-based hemostatic agents has improved hemorrhage control options. Sparse data exists on the use of these agents in the prehospital, combat setting. We describe recent use of these agents and compare patients receiving hemostatic to the baseline population., Methods: We used a series of emergency department (ED) procedure codes to identify patients within the Department of Defense Trauma Registry (DODTR) from January 2007 to August 2016. We only included patients for whom the DODTR specified the hemostatic agent utilized (chitosan or kaolin). We defined a serious injury by body region as an Abbreviated Injury Score (AIS) of 3 or greater., Results: Our predefined search codes captured 28,222 patients. Of those, 258 (0.9%) patients had documented hemostatic use: 58 chitosan, 201 kaolin, and one subject received both. Patients undergoing hemostatic agent application were more likely to be injured by gunshot wound or explosive. Patients with hemostatic application had higher median composite Injury Severity Scores (10 vs. 9, p < 0.001), and higher AIS for the abdomen, extremity and superficial body regions with higher rates of blood product utilization. Proportions of patients suffering traumatic amputations and undergoing tourniquet application were higher in the hemostatic agent group than the baseline population (11.6% vs. 6.7%, p = 0.002 and 43.4% vs. 13.8%, p < 0.001, respectively)., Conclusions: Hemostatic agents were infrequently utilized to manage traumatic hemorrhage during the recent conflicts in Afghanistan and Iraq. Hemostatic agent use was more frequent in casualties with gunshot wounds, traumatic amputations, concomitant tourniquet application, and greater blood product administration."