Combat Setting Research Articles

Prehospital Trauma Care in Disasters and Other Mass Casualty Incidents - A Proposal for Hospital-Based Special Medical Response Teams.

Current mass casualty incident (MCI) response in the United States calls for rapid deployment of first responders, such as law enforcement, fire, and emergency medical services personnel, to the incident and simultaneous activation of trauma center disaster protocols. Past investigations demonstrated that the incorporation of advanced trauma-trained physicians and paramedics into prehospital teams resulted in improved mortality during routine emergency medical care in Europe and in the combat setting. To date, limited research exists on the incorporation of advanced trauma-trained physicians and paramedics into prehospital teams for civilian MCIs.We proposed the concept of Special Medical Response Teams, which would rapidly deploy advanced trauma-trained physicians and paramedics to deliver a higher level of medical and surgical care in the prehospital setting during civilian mass casualty incidents.

Stability of Reconstituted Fibrinogen Concentrate in Hemostatic Function and Concentration.

Canadian Armed Forces adopted fibrinogen concentrate (RiaSTAP) for hemostatic resuscitation in the far-forward combat setting, given its potential benefits of reducing blood loss, blood transfusion and mortality, and its long storage stability and high portability. The current guidance recommends that RiaSTAP should be administered within 8 hours after reconstitution when stored at room temperature. However, little information about its stability is available. There is also a need to investigate the stability and efficacy of RiaSTAP after reconstitution and exposure to extreme temperatures in which our forces may operate. RiaSTAP was reconstituted as per manufacturer's instruction and stored at specific temperatures (-20°C, 4°C, 22°C, 35°C, 42°C, or 50°C) for up to 6 months. Reconstituted RiaSTAP was also oscillated on a rocker at 18 rpm under 22°C and 50°C. Its hemostatic function was measured using rotational thromboelastometry performed with RiaSTAP-spiked whole blood. Fibrinogen concentrations were measured by a commercial enzyme-linked immunosorbent assay (ELISA) kit. Gel electrophoresis was also conducted for initial and stored samples. We found no change to the hemostatic function of reconstituted RiaSTAP after storage at -20°C for 6 months. At 4°C, no obvious changes to the hemostatic effect of reconstituted RiaSTAP relative to 0 hours were seen until 1,680 hours. At 22°C, a remarkable decrease began after storage for 168 hours. Storage at 35°C significantly decreased the hemostatic effect after 144 hours, while the storage at 42°C resulted in decreased hemostatic function after 72 hours. Finally, storage at 50°C for 8 hours resulted in complete loss of hemostatic function. Compared to the hemostatic activity, the fibrinogen concentration for reconstituted RiaSTAP showed less change over time. No apparent decline in fibrinogen concentration was seen after storage at -20°C for 6 months and at 4°C for 1,680 hours. At 22°C, there were no clear alterations until 792 hours. There was a decline in fibrinogen concentration at 35°C and 42°C after 672 and 600 hours of storage, respectively. At 50°C, little amount of fibrinogen was detected by ELISA at 8 hours. Similar changes in the hemostatic effect and fibrinogen concentration over time were observed under the rocking condition in comparison with the static condition at the same temperature. The gel electrophoresis confirmed fibrinogen degradation which increased with storage temperature and time. The stability of reconstituted RiaSTAP decreases with increasing storage temperature. The hemostatic function deteriorated before fibrinogen concentration and integrity were significantly altered at all temperatures for the study period except at 50°C where there was a rapid decline in both hemostatic function and fibrinogen concentration. Sample oscillation did not significantly affect its stability. The shelf life of reconstituted RiaSTAP may, therefore, be recommended accordingly when stored at different temperatures and extended to 6 days at room temperature provided that sterility is maintained.

Inertial-based Fluidic Platform for Rapid Isolation of Blood-borne Pathogens.

Bacterial sepsis is a life-threatening disease and a significant clinical problem caused by host responses to a microbial infection. Sepsis is a leading cause of death worldwide and, importantly, a significant cause of morbidity and mortality in combat settings, placing a considerable burden on military personnel and military health budgets. The current method of treating sepsis is restricted to pathogen identification, which can be prolonged, and antibiotic administration, which is, initially, often suboptimal. The clinical trials that have been performed to evaluate bacterial separation as a sepsis therapy have been unsuccessful, and new approaches are needed to address this unmet clinical need. An inertial-based, scalable spiral microfluidic device has been created to overcome these previous deficiencies through successful separation of infection-causing pathogens from the bloodstream, serving as a proof of principle for future adaptations. Fluorescent imaging of fluorescent microspheres mimicking the sizes of bacteria cells and blood cells as well as fluorescently stained Acinetobacter baumannii were used to visualize flow within the spiral. The particles were imaged when flowing at a constant volumetric rate of 0.2 mL min-1 through the device. The same device was functionalized with colistin and exposed to flowing A. baumannii at 0.2 mL h-1. Fluorescent imaging within the channel under a constant volumetric flow rate demonstrated that smaller, bacteria-sized microspheres accumulated along the inner wall of the channel, whereas larger blood cell-sized microspheres accumulated within the center of the channel. Additionally, fluorescently stained A. baumannii displayed accumulation along the channel walls in agreement with calculated performance. Nearly 106 colony-forming units of A. baumannii were extracted with 100% capture efficiency from flowing phosphate-buffered saline at 0.2 mL h-1 in this device; this is at least one order of magnitude more bacteria than present in the blood of a human at the onset of sepsis. This type of bacterial separation device potentially provides an ideal approach for treating soldiers in combat settings. It eliminates the need for immediate pathogen identification and determination of antimicrobial susceptibility, making it suitable for rapid use within low-resource environments. The overall simplicity and durability of this design also supports its broad translational potential to improve military mortality rates and overall patient outcomes.

Implementation of mental health services in conflict and post-conflict zones: Lessons from Syria.

ABSTRACTObjective:We describe the challenges confronted and lessons learned in implementing mental healthcare during the Syrian war to inform effective services for conflict-affected Syrian populations.Materials and Methods:We searched the academic and gray literature. We draw on the experiences of Syrian-American mental health professionals with nine years of experience providing clinical and programmatic mental healthcare in combat settings, siege, internally displaced person camps, and refugee camps.Results:Collaboration with nonprofessional personnel was essential due to the shortage of formally trained mental healthcare professionals in Syria. The use of psychological and diagnostic terms increased stigma, whereas asking about the patient’s identified problem, “suffering,” or “challenges” supported engagement. War-related trauma and horizontal violence commonly affect Syrian children, adolescents, and adults. Resilience and engagement were enhanced by sensitivity to patients’ dignity, religious acceptance, and faith.Conclusions:The Syrian war remains an ongoing public health and humanitarian crisis in which mental healthcare must adapt rapidly to specific needs and resources of the patient and community. Psychiatrists can increase the acceptability and efficacy of their care by being sensitive to Syrian patients’ experiences of horizontal violence, loss of dignity, stigma, worldviews in which religion and faith may be important sources of resilience, and culturally acceptable modes of communication.

An Analysis of Prehospital Trauma Registry After-Action Reviews in Afghanistan.

After-action reviews (AARs) in the Prehospital Trauma Registry (PHTR) enable performance improvements and provide commanders feedback on care delivered at Role 1. No published data exist exploring overall trends of end-user performance-improvement feedback. We performed an expert panel review of AARs within the PHTR in Afghanistan from January 2013 to September 2014. When possible, we categorized our findings and selected relevant medical provider comments. Of 737 registered patient encounters found, 592 (80%) had AAR documentation. Most AAR patients were male (98%, n = 578), injured by explosion (48%, n = 283), and categorized for urgent evacuation (64%, n = 377). Nearly two thirds of AARs stated areas needing improvement (64%, n = 376), while the remainder left the improvement section blank (23%, n = 139) or specified no improvements (13%, n = 76). The most frequently cited areas for improvement were medical knowledge (23%, n = 136), evacuation coordination (19%, n = 115), and first responder training (16%, n = 95). Our expert panel reviewed AARs within the PHTR and found substantial numbers of AARs without improvements recommended, which limits quality improvement capabilities. Our analysis supports previous calls for better documentation of medical care in the prehospital combat setting.

Regional Anaesthesia in a Combat Setting

Background: Recent advances in combat casualty care have contributed signifi cantly to higher survival rates in previously fatal injuries from military trauma. However, most of the literature comes from international data during Operation Enduring Freedom and Operation Iraqi Freedom. Despite having conflicts, counter insurgency operations spanning over decades, very few studies in Indian scenario have analyzed injuries related to Combat and Military Trauma. Method: A retrospective observational study was done based on the records of management of military trauma cases in a zonal hospital deployed in an operational area. All trauma/ combat casualties over a one year period from Oct 2018 to Oct 2019 were included and data was segregated based on type of mechanism of trauma, limb injuries involved, and choice of anaesthesia given based on type of surgery. Results: Total 371 combat casualties were included in the study, maximum patients had splinter injuries with grenade blast (43.4%), followed by gunshot wounds (39.9%). Other injuries included mine blast (11.3%) and miscellaneous including road traffi c accidents (5.4%). Due to predominant involvement of limbs, regional anaesthesia was used most commonly (78%) and general anaesthesia was used only in 23.7% of cases. Conclusion: In our study maximum casualties were peripheral limb injuries both upper and lower limbs. Regional anaesthesia, peripheral nerve blocks for upper limb injuries and sub arachnoid block for lower limb injuries, were more commonly used in comparison to general anaesthesia (GA), while injuries involving body regions other than limbs were performed exclusively under GA.

Analysis of Prehospital Administration of Blood Products to Pediatric Casualties in Iraq and Afghanistan

Background Hemorrhage is one of the leading causes of preventable death in both military and civilian trauma. Implementation of items such as tourniquets and hemostatic dressings are helpful in controlling hemorrhage and increasing the survival rate of casualties when such injuries occur. Prehospital blood transfusions are used to treat patients with severe injuries where the standard methods of hemorrhage control are not an effective form of treatment. There is limited research and no widely accepted protocol on pediatric prehospital blood transfusions. Methods We queried the Department of Defense Trauma Registry (DODTR) for all pediatric subjects admitted to U.S. and Coalition fixed-facility hospitals in Iraq and Afghanistan from January 2007 to January 2016. This is a secondary analysis of casualties that received blood products prehospital. Results From January 2007 through January 2016 there were 3439 pediatric casualties within the registry. Within this group, 22 casualties that received one or more blood product prehospital were identified. Children in the 10–14 years age (40%) group made up the largest proportion, 86% were male, almost all were injured by explosive (63%) or firearm (27%), and 77% survived to hospital discharge. The most frequently administered blood product was packed red cells (n = 17). Of the 22, 15 underwent massive transfusion within the first 24 hours of admission. Conclusions Prehospital administration of blood products occurred infrequently within this pediatric dataset, but those that received blood were critically injured with most receiving a massive transfusion. Given the frequency with which medical personnel are carrying blood products in the prehospital, combat setting, guidelines specific to pediatric administration would be beneficial.

Mild TBI/Concussion Clinical Tools for Providers Used Within the Department of Defense and Defense Health Agency.

Military personnel are at greater risk for sustaining mild traumatic brain injury (mTBI), or concussion, whether they are in a combat or garrison setting. Consequently, mTBI is a major health concern for health practitioners to understand, in order to provide timely assessment and treatment to service members (SM) who are suspected to have mTBI. Providing early diagnosis and effective management of symptoms can optimize recovery and promote healthy outcomes. Understanding what resources and guidelines are available is important for those evaluating active duty SMs within the Military Health System. This article showcases clinical tools for screening, evaluating, and diagnosing concussion used within the US Department of Defense, and provides resources for practitioners to find these clinical tools online.

Ketamine Administration in Prehospital Combat Injured Patients With Traumatic Brain Injury: A 10-Year Report of Survival.

BackgroundThe Tactical Combat Casualty Care (TCCC) guidelines recommend ketamine as the primary battlefield analgesic in the setting of moderate-to-severe pain and hemodynamic compromise. However, despite recent studies failing to support the association between ketamine and worse outcomes in head trauma, TCCC guidelines state that ketamine may worsen severe traumatic brain injury. We compared mortality outcomes following head trauma sustained in a combat setting between ketamine recipients and non-recipients.MethodsThis is a secondary analysis of previously published data in the Department of Defense Trauma Registry from January 2007 to August 2016. We isolated patients with an abbreviated injury scale of 3 or greater for the head body region. We compared mortality between prehospital ketamine recipients and non-recipients.ResultsOur initial search yielded 28,222 patients, of which 4,183 met the inclusion criteria: 209 were ketamine-recipients and 3,974 were non-recipients. The ketamine group had a higher percentage injured by explosives (59.81% vs. 53.57%, p<0.001) and gunshot wounds (28.71% vs. 22.07%, p<0.001) and were more frequently located in Afghanistan (100% vs. 68.0%, p<0.001). The ketamine group had higher rates of tourniquet application (24.4% vs. 8.5%, p<0.001) and had lower survival proportion (75.1% alive vs. 83.0%, p=0.003). All differences were significant. On univariable analysis, the ketamine group had worse odds of survival with (OR: 0.62; 95%CI: 0.45-0.86). When controlling for the presence of an airway intervention and mechanism of injury, the finding was non-significant (OR: 1.09; 95% CI: 0.76-1.55).ConclusionsIn our prehospital combat study, after controlling for confounders, we found no association between administration of prehospital ketamine and worse survival outcomes for casualties with head injuries. However, despite the lack of difference in overall survival noted, those who received ketamine and died had a higher risk ratio for time to death.

Validation of the age-adjusted shock index for pediatric casualties in Iraq and Afghanistan

BackgroundPediatric casualties account for a notable proportion of encounters in the deployed setting based on the humanitarian medical care mission. Previously published data demonstrates that an age-adjust shock index may be a useful tool in predicting massive transfusion and death in children. We seek to determine if those previous findings are applicable to the deployed, combat trauma setting.MethodsWe 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. This is a secondary analysis of casualties seeking to validate previously published data using the shock index, pediatric age-adjusted. We then used previously published thresholds to determine patients outcome for validation by age grouping, 1–3 years (1.2), 4–6 years (1.2), 7–12 years (1.0), 13–17 years (0.9).ResultsFrom January 2007 through January 2016 there were 3439 pediatric casualties of which 3145 had a documented heart rate and systolic pressure. Of those 502 (16.0%) underwent massive transfusion and 226 (7.2%) died prior to hospital discharge. Receiver operating characteristic (ROC) thresholds were inconsistent across age groups ranging from 1.0 to 1.9 with generally limited area under the curve (AUC) values for both massive transfusion and death prediction characteristics. Using the previously defined thresholds for validation, we report sensitivity and specificity for the massive transfusion by age-group: 1–3 (0.73, 0.35), 4–6 (0.63, 0.60), 7–12 (0.80, 0.57), 13–17 (0.77, 0.62). For death, 1–3 (0.75, 0.34), 4–6 (0.66–0.59), 7–12 (0.64, 0.52), 13–17 (0.70, 0.57). However, negative predictive values (NPV) were generally high with all greater than 0.87.ConclusionsWithin the combat setting, the age-adjusted pediatric shock index had moderate sensitivity and relatively poor specificity for predicting massive transfusion and death. Better scoring systems are needed to predict resource needs prior to arrival, that perhaps include other physiologic metrics. We were unable to validate the previously published findings within the combat trauma population.

From battlefront to homefront: creation of a civilian walking blood bank

Hemorrhagic shock remains the leading cause of preventable death on the battlefield, despite major advances in trauma care. Early initiation of balanced resuscitation has been shown to decrease mortality in the hemorrhaging patient. To address transfusion limitations in austere environments or in the event of multiple casualties, walking blood banks have been used in the combat setting with great success. Leveraging the success of the region-wide whole blood program in San Antonio, Texas, we report a novel plan that represents a model response to mass casualty incidents.

Vital sign thresholds predictive of death in the combat setting.

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. 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. There were 38,769 encounters of which our dataset included 15,540 (40.1%). The median age of these patients was 25years 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 110bpm (sensitivity 52.2%, specificity 79.2%). The median systolic blood pressure was 128mmHg with area under the ROC of 0.790 with an optimal threshold to predict mortality of 112mmHg (sensitivity 68.5%, specificity 81.5%). Casualties with a systolic blood pressure <112mmHg, are at high risk of mortality, a value significantly higher than the traditional 90mmHg threshold. Our dataset highlights the need for better methods to guide resuscitation as vital sign measurements have limited accuracy in predicting mortality.

The Trauma of Autopsy and the Transgression of History in Josephus’ Jewish War

Abstract In the opening of the Jewish War, Josephus claims not only that his history represents the true and full account of the war, but that, in violation of Greek historiographical conventions, its language expresses his personal grief. Josephus’ expression of personal emotion differentiates him from the Greek tradition, in which lament is customarily expressed in other genres. Josephus borrows instead from the biblical tradition of lament to mourn the fall of Jerusalem. The concept of moral injury from trauma studies describes the psychological damage caused by betrayal in combat settings, a phenomenon which Josephus’ comments about the causes of the disaster resemble. This elucidates why Josephus emphasizes his emotions in his history, drawing on past Jewish responses to imperial-colonial encounters to shape his personalized response to the catastrophe of his own day.

ПСИХОЛОГІЧНІ ЧИННИКИ У ПРИЙНЯТТІ РІШЕННЯ КОМАНДИРОМ

Introduction. The article examines the personality of the commander in a combat setting, reveals the individual-psychological properties that must be commander in the decision-maker. The psychological factors influencing the decision-making of the commander have been determined, which consideration will determine the effectiveness of the implementation of this decision in the combat situation and in the situation of uncertainty.Purpose. Disclosure of the individual-psychological properties that must be commander in the decision-maker and the determination of the psychological factors that influence the decision-making of the commander.Methods. We have used methods of analysis, comparison, generalization and questionnaire to achieve our goal. In order to find out the main factors that hinder the decision of the commanders, we conducted a survey. The number of respondents was 171 officers.Results. The commanders were offered to select the three factors that most negatively influence their decision-making from a number of factors (novelty, suddenness, uncertainty, danger, time deficit, increased pace of action). The results of the questionnaire showed that the main factor hindering the commander's decision was uncertainty (77%). In second place, officers identified a time deficit (73%) and third place gave a suddenness (40%). Danger (30%), novelty (29%) and increased pace of action (22%) are, respectively, less significant stimuli in decision making.Originality. A number of psychological factors exert a significant influence on the decision-making process of a commander in combat. The effects of these factors on the psychological stability of the commander in the decision-making process should not be reduced. In addition, it should be emphasized that the features of emotional shifts and their nature depend primarily on the intensity of these factors.Conclusion. Having analyzed the most important psychological factors of combat that influence the decision-making process of a commander, we have identified the following factors: novelty, suddenness, uncertainty, danger, time deficit, increase in pace of action. Uncertainty is a major factor preventing the commander from deciding. The negative effect of these factors can be significantly reduced provided that systematic and importantly conscious work on mastering military and professional activity in the conditions of action of the simulated psychological factors of combat.Further research into decision-making by commanders, we see in a detailed study of the main factor that adversely affects decision-making and constantly accompanies the commander - this is uncertainty.

Freeze-Dried Extracellular Vesicles From Adipose-Derived Stem Cells Prevent Hypoxia-Induced Muscle Cell Injury.

Cellular therapies have tremendous potential for the successful treatment of major extremity wounds in the combat setting, however, the challenges associated with transplanting stem cells in the prolonged field care (PFC) environment are a critical barrier to progress in treating such injuries. These challenges include not only production and storage but also transport and handling issues. Our goal is to develop a new strategy utilizing extracellular vesicles (EVs) secreted by stem cells that can resolve many of these issues and prevent ischemic tissue injury. While EVs can be preserved by freezing or lyophilization, both processes result in decrease in their bioactivity. Here, we describe optimized procedures for EVs production, isolation, and lyophilization from primary human adipose-derived stem cells (hADSCs). We compared two isolation approaches that were ultrafiltration (UF) using a tangential fluid filtration (TFF) system and differential ultracentrifugation (UC). We also optimized EVs lyophilization in conjunction with trehalose and polyvinylpyrrolidone 40 (PVP40) as lyoprotectants. Bioactivity of EVs was assessed based on reversal of hypoxia-induced muscle cell injury. To this end, primary human myoblasts were subjected to hypoxic conditions for 6 h, and then treated with hADSC-derived EVs at a concentration of 50 μg/mL. Subsequently, muscle cell viability and toxicity were evaluated using MTS and LDH assays, respectively. Overall, nanoparticle tracking data indicated that UF/TFF yields threefold more particles than UC. Lyophilization of EVs resulted in a significantly reduced number of particles, which could be attenuated by adding lyoprotections to the freeze-drying solution. Furthermore, EVs isolated by UF/TFF and freeze-dried in the presence of trehalose significantly increased viability (P < 0.0193). Taken together, our findings suggest that the isolation and preservation methods presented in this study may enhance therapeutic applications of EVs.

Viscoelastic testing in combat resuscitation: Is it time for a new standard?

Traumatic hemorrhage and coagulopathy represent major sources of morbidity and mortality on the modern battlefield. Viscoelastic testing (VET) offers a potentially more personalized approach to resuscitation. We sought to evaluate outcomes of combat trauma patients who received VET-guided resuscitation compared with standard balanced blood product resuscitation. Retrospective analysis of the Department of Defense Trauma Registry, 2008 to 2016 was performed. Multivariate logistic regression analyses of all adult patients initially presenting to NATO Role III facilities who required blood products were performed to identify factors associated with VET-guided resuscitation and mortality. A propensity score matched comparison of outcomes in patient cohorts treated at VET versus non-VET Role III facilities was performed. There are 3,320 patients, predominately male (98%), median age ranges from 25 years to 29 years, Injury Severity Score of 18.8, with a penetrating injury (84%) were studied. Overall mortality was 9.7%. Five hundred ninety-four patients had VET during their initial resuscitation. After adjusting for confounders, VET during initial resuscitation was independently associated with decreased mortality (odds ratio, 0.63; p = 0.04). Propensity analysis confirmed this survival advantage with a 57% reduction in overall mortality (7.3% vs. 13.1%; p = 0.001) for all patients requiring blood products. Viscoelastic testing offers the possibility of a product-specific resuscitation for critically injured patients requiring transfusion in combat settings. Routine VET may be superior to non-VET-guided resuscitation for combat trauma victims. Therapeutic study, level IV.

Prehospital Use of Ketamine in the Combat Setting: A Sub-Analysis of Patients With Head Injuries Evaluated in the Prospective Life Saving Intervention Study.

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

Application of the Joint Trauma System Clinical Practice Guideline for Pain, Anxiety, and Delirium in a Combat Support Hospital in Iraq.

The 2017 Joint Trauma System Clinical Practice Guideline for Pain, Anxiety, and Delirium (JTS CPG) provides an evidence-based framework for managing pain, anxiety, and delirium in combat settings. In this study, we evaluate the use of multimodal analgesia and assess pain outcomes, as indicated by the JTS CPG, at the combat support hospital (CSH). In this quality improvement project, data were collected for all patients, presenting to the CSH in Baghdad, Iraq, who received consultation from the acute pain service from October 10, 2017 to February 27, 2018. Univariate analyses described patient demographic and clinical characteristics. Defense and Veterans Pain Rating Scale (DVPRS) scores, physical therapy completion, and sleep duration were recorded for each patient daily. Correlations assessed relationships between variables, including clinical characteristics and DVPRS scores. 34 patients were included in this study. About 65% of the patients included in this study were Iraqi military, while the other 35% were U.S. or Coalition Forces. Over half received more than one class of analgesic medication. The majority of patients received regional anesthesia, with 17 different techniques utilized. The DVPRS had acceptable internal consistency (Cronbach alpha=0.87, 95% CI 0.80, 0.95). There was a significant difference in median DVPRS pain intensity scores between those who met physical therapy goals and those who did not. Sleep duration was negatively correlated with both the DVPRS pain intensity and sleep scores. This report indicates that acute pain service teams integrated in a CSH can feasibly implement JTS CPGs using a team-based approach. Given the military's emphasis on managing complex pain and disability among survivors beginning in the combat environment, it is imperative that innovations and best practices, like the JTS CPG, be assessed in the combat setting.

Outcomes of Casualties Without Airway Trauma Undergoing Prehospital Airway Interventions: A Department of Defense Trauma Registry Study.

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. 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). 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%). 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.

The US military experience with THAM

BackgroundAcidosis, a part of the lethal trauma triad, occurs frequently after major combat trauma. Tris-hydroxymethyl aminomethane (THAM) has been used to effectively treat acidosis in injured casualties. No research has been conducted assessing the safety of THAM in the military combat setting. We sought to describe the US military experience with THAM administration to battlefield injury subjects. MethodsWe conducted a retrospective descriptive cohort study reviewing the trauma data from the Department of Defense Trauma Registry. US military personnel with an injury severity score greater than 15, between September 2001 and December 2014, were analyzed. Our primary outcome was the 30-day all-cause mortality among cohort treated with THAM versus those who were not. Differences between the cohort were examined using a student t-test (continuous variables), Wilcoxon Rank Sum test (ordinal variables), and chi-squared test (nominal variables). Results4558 subjects met the inclusion criteria. 69 received THAM and 4489 did not. Casualties receiving THAM had higher mean ISS scores (33 vs. 27, p < 0.001), and required significantly higher amounts of packed red blood cells (RBCs, 37 vs. 10, p < 0.001). THAM cohort had longer ventilator and intensive care unit (ICU) days with an overall lower survival to hospital discharge. On univariable analysis, THAM was associated with lower odds of survival (OR 0.18, 95% CI 0.11–0.31) but on multivariable analysis, when controlling for confounders, THAM use was not associated with a worse odds of survival (OR 0.83, 95% CI 0.21–3.24). ConclusionsWithin our combat trauma population, we were unable to detect worse 30 day mortality associated with THAM administration. Prospective investigations are needed to validate its use in critically injured combat casualties.