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Introduction: Orthopedic surgery constitutes 27% of procedures performed for combat injuries. General surgeons may deploy far forward without orthopedic surgeon support. This study examines the type and volume of orthopedic procedures during 15 years of combat operations in Iraq and Afghanistan.Materials and Methods: Retrospective analysis of the US Department of Defense Trauma Registry (DoDTR) was performed for all Role 2 and Role 3 facilities, from January 2002 to May 2016. The 342 ICD-9-CM orthopedic surgical procedure codes identified were stratified into fifteen categories, with upper and lower extremity subgroups. Data analysis used Stata Version 14 (College Station, TX).Results: A total of 51,159 orthopedic procedures were identified. Most (43,611, 85.2%) were reported at Role 3 s. More procedures were reported on lower extremities (21,688, 57.9%). Orthopedic caseload was extremely variable throughout the 15-year study period.Conclusions: Orthopedic surgical procedures are common on the battlefield. Current dispersed military operations can occur without orthopedic surgeon support; general surgeons therefore become responsible for initial management of all injuries. Debridement of open fracture, fasciotomy, amputation and external fixation account for 2/3 of combat orthopedic volume; these procedures are no longer a significant part of general surgery training, and uncommonly performed by general/trauma surgeons at US hospitals. Given their frequency in war, expertise in orthopedic procedures by military general surgeons is imperative. [ABSTRACT FROM AUTHOR]

The National Academies of Sciences, Engineering, and Medicine Report on Zero Preventable Deaths highlighted the need for a military and civilian partnership to take lessons learned from the wars in Iraq and Afghanistan and incorporate them into a national learning trauma care system. One of the specific objectives in the report was to establish military preventable death metrics. Upon further inspection, it became apparent that the Department of Defense did not have an established methodology to reliably estimate and report preventable death metrics and opportunities to improve the military trauma care system. Over the last year, clinical and non-clinical subject matter experts from the Joint Trauma System and Armed Forces Medical Examiners System began the process of establishing a standard military preventable death review process to meet the objective outlined in the report. Based on an assessment to understand methodological best practices for preventable death reviews, this manuscript presents the conceptual framework that is guiding our effort to establish the first ever battle-related mortality surveillance system with preventable death metrics and opportunities to improve the trauma care system. [ABSTRACT FROM AUTHOR]

Wartime vascular injury can be particularly challenging due to the complexity of the case, concomitant injuries, resource limitations, and often lack of expertise of the operating surgeon. The proliferation of vascular shunting has been of particular importance as a damage control surgery technique to restore perfusion and temporize the immediate need for definitive repair necessary for limb salvage, particularly in austere locations. Diagnosis of vascular injury can be made using a variety of techniques, from physical examination to ankle-brachial indices to the use of CT angiography or invasive angiographic techniques. Operative planning and judgment are therefore critical in deciding both how and whether to operate. Surgeons likely to deploy should take every opportunity to practice vascular exposures and techniques through clinical practice and laboratory courses. [ABSTRACT FROM AUTHOR]

Highly skilled swimmers and aquatically adaptable service members such as U.S. Navy Divers, Sea, Air and Land (SEAL) Teams, and Explosive Ordnance Disposal (EOD) technicians, die every year from drowning. Drowning is the cause of over 500,000 deaths annually across the globe. This Clinical Practice Guideline (CPG) provides an overview of drowning and associated conditions based on the best available current medical evidence. Unlike basic life support and advanced cardiac life support protocols, rescue breathing should be initiated prior to chest compressions to re-expand water-filled alveoli. These guidelines should be used as a standardized framework to guide first responders, prehospital emergency medical service personnel, and medical department personnel in evaluating, diagnosing, and managing common in water pathologies. [ABSTRACT FROM AUTHOR]

This article forms part of a series that will explore the effect that Role 2 (R2) medical treatment facilities (MTFs) had on casualty care during the military campaign in Afghanistan and how we should interpret this to inform the capabilities in, and training for future R2 MTFs. Key aspects of doctrine which influence the effectiveness of R2 MTFs include timelines to care, patient movement capabilities, and MTF capabilities. The focus of this analysis was to review allied doctrine from the United States, United Kingdom, and the North Atlantic Treaty Organization to identify similarities and differences regarding employment of R2 related medical assets in the Afghan Theater, specifically for trauma care. Several discrepancies in medical doctrine persist among allied forces. Timelines to definitive care vary among nations. Allied nations should have clear taxonomy that clearly defines MTF capabilities within the combat casualty care system. The R2 surgical capability discrepancy between United States and North Atlantic Treaty Organization doctrine should be reconciled. Medical evacuation capabilities on the battlefield would be improved with a taxonomy that reflected the level of capability. Such changes may improve interoperability in a dynamic military landscape. [ABSTRACT FROM AUTHOR]

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

The article discusses the joint trauma system and the uncertainty that is the fog of war focusing on developments made in military medicine and rates of mortality due to war casualties. Topics include developments in medical technology, Damage Control Resuscitation, and data collected by trauma registry. Also discussed is the role played by the US Department of defence.

Unlike penetrating abdominal injuries where the decision to operate is relatively straight forward, those combat casualties that sustain blunt abdominal trauma offer more of a diagnostic and clinical challenge. For unstable patients with a positive focused abdominal sonography in trauma or diagnostic peritoneal lavage, exploratory laparotomy should be undertaken immediately. All grade IV-V splenic injuries should undergo splenectomy, patients undergoing attempted splenic salvage should be monitored in the Role 3 facility and embolization of such splenic injuries may be considered if available. Patients who fail non-operative management of the spleen require splenectomy at the Role 3 prior to aeromedical evacuation. Overwhelming post-splenectomy infection is a serious disease that can progress from a mild flu-like illness to fulminant sepsis in a short period of time. Although relatively rare, it has a high mortality rate with delayed or inadequate treatment. All splenectomized patients and those deemed to be functionally asplenic should be vaccinated within 14 days from splenectomy and prior to aeromedical evacuation. [ABSTRACT FROM AUTHOR]

Surgery has traditionally been the definitive form of invasive management for renal vascular injuries. There is a growing trend in the use of endovascular techniques as an alternative to surgery in the trauma setting. We present the case of a 24-year-old woman with an acute renal arteriovenous fistula caused by a stab wound in the left flank, which was successfully managed with selective arterial embolization. This represents only the second reported case of such an approach in the acute setting. [ABSTRACT FROM AUTHOR]

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

A 62-year-old man was first seen with acute pancreatitis with diffuse intrapancreatic gas and pneumoperitoneum. An immediate exploratory operation revealed diffuse pancreatic necrosis but no perforated viscus; postoperatively, the patient rapidly died. This case represents a constellation of extremely rare findings: Clostridium perfringens infection of the pancreas, pancreatic emphysema or “gas gangrene,” and pneumoperitoneum without a perforated viscus. [Copyright &y& Elsevier]

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

Presents a case of spontaneous splenic rupture requiring splenectomy in a U.S. Marine patient with no symptoms of infectious mononucleosis. Physical examination of the patient; Percentage of overwhelming postsplenectomy infection risk in adults; Administration of vaccines after splenectomy.

Introduction: Genitourinary surgery constitutes approximately 1.15% of procedures performed for combat injuries. During forward deployment, surgeons usually deploy without urology support. To better understand the training and skills maintenance needs for genitourinary procedures by describing in detail the genitourinary surgical workload during 15 years of combat operations and compare our findings with those from previously published articles.Material and Methods: A retrospective analysis of the Department of Defense Trauma Registry (DoDTR) was performed for all Roles 2 and 3 medical treatment facilities in Iraq and Afghanistan, from January 2002 to May 2016. The 177 ICD-9-CM procedure codes identified as genitourinary procedures were grouped into 15 anatomic categories by subject matter experts. Select groups were further subdivided by procedure types. Descriptive analyses were performed and stratified workload percentiles were calculated for the 10th, 50th, and 90th percentiles. Data analysis was performed using Stata Version 14 (College Station, TX, USA). This quality improvement project was deemed exempt from institutional review board review by the U.S. Army Institute of Surgical Research.Results: A total of 3,963 genitourinary surgical procedures were identified, the majority occurring at Role 3 medical treatment facilities (3,512, 88.6%). The most common procedure groups were testis (20.6%), bladder (18.8%), scrotum (17.7%), and kidney (13.5%). The single most common individual procedures performed were unilateral orchiectomy (394, 9.9%), suture of laceration of scrotum and tunica vaginalis (373, 9.4%), nephroureterectomy (360, 9.1%), and other suprapubic cystostomy (268, 6.8%). Of the 77 gynecological procedures, 15 were C-sections. Genitourinary caseload per facility was low, never exceeding nine procedures per month.Conclusions: All deploying surgeons may be required to evaluate, stage, and surgically manage genitourinary, gynecologic, and obstetrical conditions. Surgery on the male genitalia, bladder, and kidney were the most commonly required genitourinary operative procedures in deployed facilities; therefore, non-urological surgeons should receive pre-deployment training in these techniques. The workload data from our study can be used to help guide the development of pre-deployment training to ensure military surgeons have the skills to perform the specialty procedures required while deployed. [ABSTRACT FROM AUTHOR]

The article article discusses the Joint Trauma System focusing on the history of JTS and efforts made to improve combat casualty care as JTS organizes and coordinates battlefield care to minimize morbidity and mortality and optimize the ability to provide essential care required for casualty injuries. Topics include building of trauma registry for combat casualty care, role played by the US Department of Defense, and Wartime medical system.

Presents an account of a physician in Iraq during the war and treating a soldier from the United States that had been shot in the back. Speculation on whether the soldier will survive; Death of the soldier; How his death made the war seem more real for the physician and his surgical unit.

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

A personal narrative is presented which explores the author's experience of attending to the medical needs of U.S. troops deployed to Afghanistan.

Presents a letter to the editor in response to the article "Is this patient dead, vegetative or severely neurologically impaired? assessing outcome for comatose survivors of cardiac arrest," by Christopher Booth and Allan Detsky.

The article provides a photograph of a rupturing aneurysm of the posterior inferior cerebellar artery of a 35-year-old woman.

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

Introduction: Tactical Combat Casualty Care (TCCC) is the execution of prehospital trauma skills in the combat environment. TCCC was recognized by the 2018 Department of Defense Instruction on Medical Readiness Training as a critical wartime task. This study examines the training, understanding, and utilization of TCCC principles and guidelines among US Army medical providers and examines provider confidence of medics in performing TCCC skills.Materials and Methods: A cross-sectional survey, developed by members of the Committee on TCCC, was distributed to all US Army Physicians and Physician Assistants via anonymous electronic communication.Results: A total of 613 completed surveys were included in the analyses. Logistic regression analyses were conducted on: TCCC test score of 80% or higher, confidence with medic utilization of TCCC, and medic utilization of ketamine in accordance with TCCC.Conclusions: <60% of respondents expressed confidence in the ability of the medics to perform all TCCC skills. Supervising providers who that believed 80 to 100% of their medics had completed TCCC training had more confidence in their medic's TCCC abilities. With TCCC, a recognized lifesaver on the battlefield, continued training and utilization of TCCC concepts are paramount for deploying personnel. [ABSTRACT FROM AUTHOR]

Acute respiratory distress syndrome (ARDS) is a condition affecting critically ill patients, characterized by pulmonary inflammation and defects in oxygenation due to either direct or indirect injury to the lungs. These guidelines will define the diagnosis and management of ARDS, particularly among combat casualties and patients in the deployed environment. The cornerstone of management of ARDS involves maintaining adequate oxygenation while avoiding further pulmonary injury through lung-protective ventilation. Additional strategies for advanced respiratory failure, such as prone positioning, neuromuscular blockade, and extracorporeal membrane oxygenation will be reviewed here as well. Particularly important to the care of the patient with ARDS in the deployed environment is a familiarity with the challenges and indications for transport/aeromedical evacuation. [ABSTRACT FROM AUTHOR]

Hearing is a critical sense to military performance. The ability to detect, identify, and localize sounds, the ability to maintain spatial awareness on the battlefield and the awareness to control one's own noise production can be vital to troop's stealth, survivability, and lethality. Hazardous noise is an environmental public health threat encountered in training at war, and in many off-duty activities. The risk to hearing and the resultant damage from any of these hazardous exposures is generally invisible, insidious and cumulative. Regardless of the source of injury, hearing loss degrades the sensor that integrates Service Members with their environment, provides for unity of effort, and ensures command and control.Acoustic trauma-induced hear loss and tinnitus are the two most prevalent disabilities in veterans, with over 765,000 cases in the Gulf War era alone. To counter this threat, it is necessary to push for early identification and early intervention through a trusted surveillance system. Success will require advocacy, education, and encouragement of self-reporting for evaluation following symptomatic noise exposures. This Clinical Practice Guideline (CPG) is a step to ensure the hearing health, readiness, protection, and care of Service Members. This will in turn optimize troop performance and minimize injury risk and mishap. [ABSTRACT FROM AUTHOR]

A catastrophic brain injury is defined as any brain injury that is expected to result in permanent loss of all brain function above the brain stem level. These clinical recommendations will help stabilize the patient so that they may be safely evacuated from theater. In addition to cardiovascular and hemodynamic goals, special attention must be paid to their endocrine dysfunction and its treatment-specifically steroid, insulin and thyroxin (t4) replacement while evaluating for and treating diabetes insipidus. Determining the futility of care coupled with resource management must also be made at each echelon. Logistical coordination and communication is paramount to expedite these patients to higher levels of care so that there is an increased probability of reuniting them with their family. [ABSTRACT FROM AUTHOR]

There is a widely prevailing belief that electronic health records and data registries are the same, or that registries can be replaced by electronic health records given the advances in technology. While information systems have revolutionized documentation of medical care, distinctions continue to exist. This article will clear the confusion between the two systems, using the Joint Trauma System's (JTS) Department of Defense (DoD) Trauma Registry (DoDTR), the approved enterprise wide trauma registry for the military, as an example. [ABSTRACT FROM AUTHOR]

An improved understanding of the pathophysiology of combat trauma has evolved over the past decade and has helped guide the anesthetic care of the trauma patient requiring surgical intervention. Trauma anesthesia begins before patient arrival with warming of the operating room, preparation of anesthetic medications and routine anesthetic machine checks. Induction of anesthesia must account for potential hemodynamic instability and intubation must consider airway trauma. Maintenance of anesthesia is accomplished with anesthetic gas, intravenous infusions or a combination of both. Resuscitation must precede or be ongoing with the maintenance of anesthesia. Blood product transfusion, antibiotic administration, and use of pharmacologic adjuncts (e.g., tranexamic acid, calcium) all occur simultaneously. Ventilatory strategies to mitigate lung injury can be initiated in the operating room, and resuscitation must be effectively transitioned to the intensive care setting after the case. Good communication is vital to efficient patient movement along the continuum of care. The resuscitation that is undertaken before, during and after operative management must incorporate important changes in care of the trauma patient. This Clinical Practice Guideline hopes to provide a template for care of this patient population. It outlines a method of anesthesia that incorporates the induction and maintenance of anesthesia into an ongoing resuscitation during surgery for a trauma patient in extremis. [ABSTRACT FROM AUTHOR]

Whole blood is the preferred product for resuscitation of severe traumatic hemorrhage. It contains all the elements of blood that are necessary for oxygen delivery and hemostasis, in nearly physiologic ratios and concentrations. Group O whole blood that contains low titers of anti-A and anti-B antibodies (low titer group O whole blood) can be safely transfused as a universal blood product to patients of unknown blood group, facilitating rapid treatment of exsanguinating patients. Whole blood can be stored under refrigeration for up to 35 days, during which it retains acceptable hemostatic function, though supplementation with specific blood components, coagulation factors or other adjuncts may be necessary in some patients. Fresh whole blood can be collected from pre-screened donors in a walking blood bank to provide effective resuscitation when fully tested stored whole blood or blood components are unavailable and the need for transfusion is urgent. Available clinical data suggest that whole blood is at least equivalent if not superior to component therapy in the resuscitation of life-threatening hemorrhage. Low titer group O whole blood can be considered the standard of care in resuscitation of major hemorrhage. [ABSTRACT FROM AUTHOR]

High, combat-related bilateral lower extremity amputations rarely occur in isolation. Dismounted complex blast injury is a devastating and life-threatening constellation of multisystem injuries most commonly due to dismounted contact with improvised explosive devices. Rapid damage control resuscitation and surgery are essential to improve patient survival and minimize both early complications and late sequelae. A coordinated team approach is essential to provide simultaneous airway management, volume resuscitation (ideally with whole blood or ratio transfusion), and immediate control of life-threatening hemorrhage. Temporary aortic or iliac vessel clamping during concurrent exploratory or vascular control laparotomy is frequently required. Stabilization of unstable pelvic fractures is then performed, followed by debridement and irrigation of all wounds, which should be left open, and subsequent provisional stabilization of long bone fractures. The goal of the initial surgical resuscitative endeavor is rapid concurrent control of all sources of hemorrhage to avoid the lethal triad of acidosis, hypothermia and coagulopathy. To this end, multiple surgeons or surgical teams should be utilized whenever feasible. Patients then require ongoing resuscitation followed by early and frequent return to the operating suite throughout the evacuation chain. Utilizing this approach, a high survival rate with reasonable functional outcomes is achievable despite the extreme severity of the DCBI pattern. [ABSTRACT FROM AUTHOR]

Resuscitative thoracotomy has been extensively described in the civilian trauma literature and has a high mortality rate, due largely to the nature of the injuries leading to arrest. The survival rates are generally highest (10-30%) for penetrating truncal injuries and patients who arrive with vital signs and proceed to arrest or who have impending arrest. They are significantly lower (less than 5%) for blunt trauma victims, particularly those who arrest in the field or during transport (1% or less). In addition, the likelihood of survival with intact neurologic function is significantly lower than the overall survival rates, particularly for blunt trauma victims and for prehospital arrest. [ABSTRACT FROM AUTHOR]

Historically, cold injury, hypothermia, and frostbite have been severe problems for military units on the battlefield. Kenneth D. Orr and David C. Fainer captured these difficulties in their book, Cold Injuries in Korea During Winter of 1950-51, still cited in military medical readiness training. While not common in modern conflicts, the potential exists for large numbers of these casualties in war and during training. [ABSTRACT FROM AUTHOR]

Acute compartment syndrome (CS) is a frequent and potentially devastating complication of blunt and penetrating extremity injuries. Extremity war injuries are particularly susceptible to CS due to associated vascular injuries; high Injury Severity Score; extensive bone and soft tissue injury; and frequent transportation that may limit close monitoring of the injured extremity. Treatment consists of prompt fasciotomy of all compartments in the involved segment, over their full length. Delayed or incomplete fasciotomy is associated with worse outcomes, including muscle necrosis, infection, and amputation. Enhanced pre-deployment training of surgeons decreases the need for revision fasciotomy at higher echelons of care and should be continued in future conflicts. We recommend the liberal use of prophylactic fasciotomy prior to aeromedical evacuation and after limb reperfusion. For leg fasciotomy, we recommend a two-incision approach as it is more reproducible and allows easy vascular exposure when necessary. [ABSTRACT FROM AUTHOR]

Acute kidney injury is a recognized complication of combat trauma. The complications associated with acute kidney injury, such as life-threatening hyperkalemia, are usually delayed in onset. In the recent conflicts, rapid evacuation of U.S. and coalition personnel generally resulted in these complications occurring at higher echelons of care where renal replacement therapies were available. In the future however, deployed providers may not have this luxury and should be prepared to temporize patients while they await transport. In this clinical practice guideline, recommendations are made for the management of patients with, or at risk for, acute kidney injury and hyperkalemia in the austere, deployed environment. [ABSTRACT FROM AUTHOR]

Management of the patient with moderate to severe brain injury in any environment can be time consuming and resource intensive. In the austere or hostile environment, the challenges to deliver care to this patient population are magnified. These guidelines have been developed by acknowledging commonly recognized recommendations for neurosurgical and neuro-critical care patients and augmenting those evaluations and interventions based on the experience of neurosurgeons, trauma surgeons, and intensivists who have delivered care during recent coalition conflicts. [ABSTRACT FROM AUTHOR]

Management of wartime burn casualties can be very challenging. Burns frequently occur in the setting of other blunt and penetrating injuries. This clinical practice guideline provides a manual for burn injury assessment, resuscitation, wound care, and specific scenarios including chemical and electrical injuries in the deployed or austere setting. The clinical practice guideline also reviews considerations for the definitive care of local national patients, including pediatric patients, who are unable to be evacuated from theater. Medical providers are encouraged to contact the US Army Institute of Surgical Research (USAISR) Burn Center when caring for a burn casualty in the deployed setting. [ABSTRACT FROM AUTHOR]

The purpose of this Clinical Practice Guideline is to provide an approach for optimal nutritional support in the postinjury period for those injured in combat. Indications and contraindications for enteral and parenteral nutrition are addressed. Timing of nutritional support, nutritional goals, energy requirements, and ideal formula selection for various types of traumatic injuries are addressed. Challenges encountered providing nutrional support for the traumatically injured in the deployed environment are also discussed. [ABSTRACT FROM AUTHOR]

The purpose of this Clinical Practice Guide is to provide details on the procedures to safely remove unexploded ordnance from combat patients, both loose and impaled, to minimize the risks to providers and the medical treatment facility while ensuring the best outcome for the patient. Military ordnance, to include bullets, grenades, flares, and explosive ordnance, retained by a patient can be a risk to all individuals and equipment along the continuum of care. This is especially true from the point of injury to the first treatment facility. Management of patients with unexploded ordnance either on or in their body is a rare event during combat surgery. Loose munitions are usually noted and easily removed prior to the patient receiving medical treatment. However, impaled munitions provide a significant challenge. These are usually caused by large caliber, high-velocity projectiles. Patients who survive to arrive at a treatment facility must be triaged safely and simultaneously treated appropriately to ensure both the survival of the patient and the treatment team. Between WWII and the Somalia conflict, there have been 36 reported cases of unexploded ordnance from U.S. soldiers. Since 2005, there have been six known cases during the U.S. wars in Afghanistan and Iraq and one additional case in Pakistan. Optimal outcomes require a basic knowledge of explosives and triggering mechanisms, as well as adherence to basic principles of trauma resuscitation and surgery. [ABSTRACT FROM AUTHOR]

Medical imaging plays a critical role in the rapid diagnosis, effective triage, and management of complex poly-trauma patients. High-quality medical imaging can be accomplished successfully in a deployed or wartime setting. Due to advances in aggressive resuscitation techniques and the speed of the latest generation computed tomography scanners (64-detector and beyond), rapid trauma scans utilizing computed tomography and ultrasound imaging can routinely be performed prior to taking the patient to the operating room potentially providing the trauma team with lifesaving information. This clinical practice guideline provides an overview of the imaging modalities available in austere settings, the equipment required, and the role that each plays in triaging and diagnosis of the acutely injured poly-trauma patients. [ABSTRACT FROM AUTHOR]

Background US Navy nurses provide en route care for critically injured combat casualties without having a formal program for training, utilization, or evaluation. Little is known about missions supported by Navy nurses. Objectives To characterize the number and types of patients transported and skill sets required by Navy nurses during 2 combat support deployments. Methods All interfacility casualty transfers between 2 separate facilities in Iraq and Afghanistan were assessed. Number of patients treated, number transported, en route care provider type, transport priority level and duration, injury severity, indication for critical care transport, en route care interventions, and vital signs were evaluated. Results Of 1550 casualties, 630 required medical evacuation to a higher level of care. Of those, 133 (21%) were transported by a Navy nurse, with 131 (98.5%) classified as "urgent," accounting for 46% of all urgent transports. The primary indication for en route care nursing was mechanical ventilation of intubated patients (97%). Mean (SD) patient transport time was 29.8 (7.9) minutes (range, 17-61 minutes). The most common en route care interventions were administration of intravenous sedation (80%), neuromuscular blockade (79%), and opioids (48%); transfusions (18%); and ventilation changes (11%). No intubations, cricothyroidotomies, chest tube placements, or needle decompressions were performed en route. No deaths occurred during transport. Conclusions US Navy nurses successfully transported critically injured patients without observed adverse events. Establishing en route care as a program of record in the Navy will facilitate continuous process improvement to ensure that future casualties receive optimized en route care. [ABSTRACT FROM AUTHOR]

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

Introduction: In 2006, burn clinical practice guidelines were developed to provide recommendations for optimal care of U.S. military and local national burn casualties. As part of that effort, a paper-based Burn Flow Sheet (BFS) was included to document the burn resuscitation of combat casualties with ≥20% total body surface area burns. The purpose of this study was to evaluate the BFS in terms of ongoing utilization, resuscitation management, and outcomes of patients transported.Materials and Methods: A retrospective review was performed of hard-copy BFSs received from January 2007 to December 2013. En route injury and treatment data from these flowsheets were manually transcribed into the research database. Outcomes and complications of BFS subjects were extracted from the Burn Center Registry and added to the research database.Results: A total of 73 BFSs were collected from the study period. On average, BFSs were 61 ± 30% complete with a total of 14.7 ± 7 hours documented per patient in the first 24-hours postburn. Patients received nearly 7 L more fluid than estimated by traditional formulas. Sixteen patients (26%) received greater than 250 mL/kg of fluid, half of whom had concomitant traumatic injuries. Fifteen patients received a fasciotomy (21%), 4 received a laparotomy (5%), and 8 (11%) received both. No patients developed abdominal compartment syndrome associated with fluid resuscitation. Overall mortality was 21%.Conclusions: Although the majority of providers did initiate a BFS, it was not always used as intended; problems included missing data and miscalculations. Although there was a clear improvement with decline in the incidence of abdominal compartment syndrome, mortality did not change for severely burned patients. Simplification of the recommendations, additional built-in prompts, and automated tools such as computerized decision support software may help standardize practice and improve outcomes. [ABSTRACT FROM AUTHOR]

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

The article discusses Joint Trauma System (JTS) Clinical Practice Guidelines (CPGs) were developed out of necessity to reduce variability in clinical care, improve quality of care, measure outcomes, and weigh the benefits against the risks and costs of specific interventions. Topics include Clinical Practice Guidelines (CPG) compliance, role played by Department of Defense (DoD) trauma cases, and analysis of combat casualty data.

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

Fractures continue to account for a large proportion of combat-related injuries. The basic tenets of irrigation, debridement, soft tissue care, and vigilant monitoring/fasciotomy for acute compartment syndrome persist. Closed management of fractures with splinting or casting is acceptable. If time and facility allow, external fixation of fractures offer many advantages over closed treatment but require knowledge, experience and skill in the safe placement of pins. The care of host nationals presents unique challenges and deployed surgeons must be flexible and resourceful in these situations. [ABSTRACT FROM AUTHOR]

Combat extremity injury and amputation is a life threatening injury. Initial surgical care should focus on hemostasis followed by irrigation and debridement of contaminated and nonviable tissue. Preservation of limb length begins at the initial surgical procedure, to include retention of atypical soft tissue flaps for later reconstruction and treatment of proximal fractures. Serial irrigation and debridements are required throughout the MEDEVAC system as the evolving zone of injury becomes more mature, followed by the appropriate timing of closure outside the combat theater. [ABSTRACT FROM AUTHOR]