Remote Damage Control Resuscitation Research Articles

Future strategies for remote damage control resuscitation after traumatic hemorrhage.

Naumann, David N. PhD; Khan, Mansoor A. PhD; Smith, Jason E. MD; Rickard, Rory PhD; Woolley, Tom MD Author Information

Damage Control Resuscitation.

Damage control resuscitation (DCR) is a strategy for resuscitating patients from hemorrhagic shock to rapidly restore homeostasis. Efforts are focused on blood product transfusion with whole blood or component therapy closely approximating whole blood, limited use of crystalloid to avoid dilutional coagulopathy, hypotensive resuscitation until bleeding control is achieved, empiric use of tranexamic acid, prevention of acidosis and hypothermia, and rapid definitive surgical control of bleeding. Patients receiving uncrossmatched Type O blood in the emergency department and later receiving cumulative transfusions of 10 or more red blood cell units in the initial 24-hour post-injury (massive transfusion) are widely recognized as being at increased risk of morbidity and mortality due to exsanguination. Ideally, these patients should be rapidly identified, however anticipating transfusion needs is challenging. Useful indicators of massive transfusion reviewed in this guideline include: systolic blood pressure <110 mmHg, heart rate > 105 bpm, hematocrit <32%, pH < 7.25, injury pattern (above-the-knee traumatic amputation especially if pelvic injury is present, multi-amputation, clinically obvious penetrating injury to chest or abdomen), >2 regions positive on Focused Assessment with Sonography for Trauma (FAST) scan, lactate concentration on admission >2.5, admission international normalized ratio ≥1.2-1.4, near infrared spectroscopy-derived StO2 < 75% (in practice, rarely available), BD > 6 meq/L. Unique aspects of out-of-hospital DCR (point of injury, en-route, and remote DCR) and in-hospital (Medical Treatment Facilities: Role 2b/Forward surgical teams - role 3/ combat support hospitals) are reviewed in this guideline, along with pediatric considerations.

Red tides: Mass casualty and whole blood at sea.

The U.S. Navy's casualty-receiving ships provide remote damage control resuscitation platforms to treat injured combatants deployed afloat and ashore. We report a significant mass casualty incident aboard the USS Bataan, and the most warm fresh whole blood (WFWB) transfused at sea for traumatic hemorrhagic shock since the Vietnam War. Casualty-receiving ships have robust medical capabilities, including a frozen blood bank with packed red blood cells (pRBC) and fresh frozen plasma (FFP). The blood supply can be augmented with WFWB collected from a "walking blood bank." Following a helicopter crash, six patients were transported by MV-22 Osprey to the USS Bataan. Patient 1 had a pelvic fracture, was managed with a pelvic binder, and received 4 units of pRBC, 2 units of FFP, and 6 units of WFWB. Patient 2, with a comminuted tibia and fibula fracture, underwent lower extremity four-compartment fasciotomy, and received 4 units of WFWB. Patient 3 underwent several procedures, including left anterior thoracotomy, aortic cross-clamping, exploratory laparotomy, small bowel resection, and tracheostomy. He received 8 units of pRBC, 8 units of FFP, and 28 units of WFWB. Patients 4 and 5 had suspected spine injuries and were managed nonoperatively. Patient 6, with open tibia and fibula fractures, underwent lower extremity four-compartment fasciotomy with tibia external fixation and received 1 unit of WFWB. All patients survived aeromedical evacuation to a role 4 medical facility and subsequent transfer to local hospitals. Maritime military mass casualty incidents are challenging, but the U.S. Navy's casualty-receiving ships are ready to perform remote damage control resuscitation at sea. Activation of the ship's walking blood bank to transfuse WFWB is essential for hemostatic resuscitations afloat. Study type: case series, level V.

Trauma Hemostasis and Oxygenation Research Network position paper on the role of hypotensive resuscitation as part of remote damage control resuscitation.

The Trauma Hemostasis and Oxygenation Research (THOR) Network has developed a consensus statement on the role of permissive hypotension in remote damage control resuscitation (RDCR). A summary of the evidence on permissive hypotension follows the THOR Network position on the topic. In RDCR, the burden of time in the care of the patients suffering from noncompressible hemorrhage affects outcomes. Despite the lack of published evidence, and based on clinical experience and expertise, it is the THOR Network's opinion that the increase in prehospital time leads to an increased burden of shock, which poses a greater risk to the patient than the risk of rebleeding due to slightly increased blood pressure, especially when blood products are available as part of prehospital resuscitation.The THOR Network's consensus statement is, "In a casualty with life-threatening hemorrhage, shock should be reversed as soon as possible using a blood-based HR fluid. Whole blood is preferred to blood components. As a part of this HR, the initial systolic blood pressure target should be 100 mm Hg. In RDCR, it is vital for higher echelon care providers to receive a casualty with sufficient physiologic reserve to survive definitive surgical hemostasis and aggressive resuscitation. The combined use of blood-based resuscitation and limiting systolic blood pressure is believed to be effective in promoting hemostasis and reversing shock".

Adaptive and platform trials in remote damage control resuscitation.

The traditional approach to clinical trial design requires assuming precise values for multiple unknown parameters, resulting in a trial design that is unlikely to perform well if one or more of those assumptions turn out to be incorrect. During conduct of the trial, trial characteristics are often held fixed, even if incoming data suggest that one or more design assumptions were incorrect. This leads to an increased risk of a failed trial. In contrast, an adaptive clinical trial is designed to take advantage of partial, incoming data during the conduct of the trial, modifying key clinical trial characteristics according to prespecified rules, in order to avoid a failed or inconclusive trial, improve statistical efficacy, better treat patients within the trial, or achieve other scientific or ethical goals. The concept of an adaptive trial can be expanded to a platform trial, a clinical trial that is intended to evaluate multiple treatments or combinations of treatments, often for patients with any of a group of related diseases, and to continue beyond the evaluation of any particular treatment. Platform trial design strategies can be applied to the problem of finding the best treatment strategy for patients suffering from posttraumatic hemorrhagic shock. We present the rationale and considerations surrounding adaptive and platform trial design and apply these concepts to the problem of investigating strategies for remote damage control resuscitation.

Fibrinogen Concentrate in the Special Operations Forces Environment.

Hemorrhage is the most common cause of death among Special Operations Force (SOF) soldiers. Bringing remote damage control resuscitation into the far-forward combat environment is logistically challenging, as it requires blood products that generally require a robust cold chain. Alternatively, lyophilized products such as fibrinogen concentrate, which does not require thawing or blood group compatibility testing before use, might be advantageous in damage control resuscitation in the battlefield. In this report, we review the evidence for the use of fibrinogen concentrate in the Canadian SOF environment. The literature on the use of fibrinogen concentrate in the trauma setting was reviewed by Canadian Forces Services Working Group, in three separate meetings. Multiple stakeholders were consulted to obtain authoritative perspectives from subject matter experts on the use of fibrinogen concentrate in the Canadian SOF environment. We also conducted a comparison review of fibrinogen content, pathogen risk, shelf life, and methods required for use for fresh frozen plasma, cryoprecipitate, and fibrinogen concentrate relevant to their application in the far-forward combat environment. Indications and a protocol for the use of fibrinogen as an adjunct to fresh whole blood were formulated based on a literature review and clinical expert opinion. Alternative strategies and other lyophilized blood products were considered before selecting fibrinogen concentrate as the lyophilized blood product of choice. Fibrinogen concentrate is an ABO-universal blood product with an excellent safety profile. Training was conducted by subject matter experts within civilian trauma centers and at military training facilities. The clinical efficacy and safety were confirmed by monitoring the use of fibrinogen concentrate in deployed combat settings. Fibrinogen concentrate is a useful adjunct to remote damage control resuscitation in the SOF environment. Fibrinogen concentrate was found to be robust for transport into the SOF environment and is widely accepted among SOF operators and medics.

Just chill—it's worth it!

Just chill—it's worth it!

Damage control: Concept and implementation

The concept of damage control (DC) is based on a sequential therapeutic strategy that favors physiological restoration over anatomical repair in patients presenting acutely with hemorrhagic trauma. Initially described as damage control surgery (DCS) for war-wounded patients with abdominal penetrating hemorrhagic trauma, this concept is articulated in three steps: surgical control of lesions (hemostasis, sealing of intestinal spillage), physiological restoration, then surgery for definitive repair. This concept was quickly adapted for intensive care management under the name damage control resuscitation (DCR), which refers to the modalities of hospital resuscitation carried out in patients suffering from traumatic hemorrhagic shock within the context of DCS. It is based mainly on specific hemodynamic resuscitation targets associated with early and aggressive hemostasis aimed at prevention or correction of the lethal triad of hypothermia, acidosis and coagulation disorders. Concomitant integration of resuscitation and surgery from the moment of admission has led to the concept of an integrated DCR-DCS approach, which enables initiation of hemostatic resuscitation upon arrival of the injured person, improving the patient's physiological status during surgery without delaying surgery. This concept of DC is constantly evolving; it stresses management of the injured person as early as possible, in order to initiate hemorrhage control and hemostatic resuscitation as soon as possible, evolving into a concept of remote DCR (RDCR), and also extended to diagnostic and therapeutic radiological management under the name of radiological DC (DCRad). DCS is applied only to the most seriously traumatized patients, or in situations of massive influx of injured persons, as its universal application could lead to a significant and unnecessary excess-morbidity to injured patients who could and should undergo definitive treatment from the outset. DCS, when correctly applied, significantly improves the survival rate of war-wounded.

Prehospital Transfusion for Gastrointestinal Bleeding

ObjectiveGastrointestinal (GI) bleeding is a common medical emergency with significant morbidity and mortality. Many patients are coagulopathic, which may perpetuate bleeding. Remote damage control resuscitation, including early correction of coagulopathy and anemia, may benefit exsanguinating patients with GI bleeding. MethodsWe conducted a retrospective review of patients with acute GI bleeding who received packed red blood cells (pRBC) and/or plasma during transportation to our institution between 2010 and 2014. A comparison group of patients who were not transfused en route was selected, and demographics, outcomes, and response to resuscitation were compared. ResultsA total of 112 patients with GI bleeding received pRBC (82%, n = 92 pRBC, mean 1.7 ± 0.9 units), plasma (62%, n = 69, mean 1.7 ± 0.8 units) or both (44%, n = 49) en-route. The comparison group comprised 49 patients transported by helicopter who were not transfused en-route. Demographics, crystalloid resuscitation, transfusion prior to transfer, rate of intervention, ICU days, length of stay, and mortality were similar between groups. Patients transfused en route had a significant increase in hemoglobin from 8.3 ± 2.2 to 8.9 ± 2.1 (P = .03) and decrease in INR from 2.0 ± 1.0 to 1.6 ± 1.4 (P = .01), whereas those not transfused en route experienced stable hemoglobin (8.7 ± 2.8 to 9.4 ± 2.5; P = .21) and INR values (1.9 ± 1.0 to 1.6 ± 1.4; P = .32). Both groups had a significant improvement in hemodynamic parameters with resuscitation. ConclusionPrehospital damage control resuscitation with pRBC and/or plasma resulted in the improvement of hemodynamic instability, coagulopathy and anemia in patients with acute GI bleeding. Almost all patients required additional inpatient interventions and/or transfusions, suggesting that pre-hospital transfusion is being utilized for appropriately selected patients.

Leadership and a casualty response system for eliminating preventable death.

Combat casualties who die from their injuries do so primarily in the prehospital setting. Although most of these deaths result from injuries that are nonsurvivable, some are potentially survivable. Of injuries that are potentially survivable, most are from hemorrhage. Thus, military organizations should direct efforts toward prehospital care, particularly through early hemorrhage control and remote damage control resuscitation, to eliminate preventable death on the battlefield. A systems-based approach and priority of effort for institutionalizing such care was developed and maintained by medical personnel and command-directed by nonmedical combatant leaders within the 75th Ranger Regiment, U.S. Army Special Operations Command. The objective of this article is to describe the key components of this prehospital casualty response system, emphasize the importance of leadership, underscore the synergy achieved through collaboration between medical and nonmedical leaders, and provide an example to other organizations and communities striving to achieve success in trauma as measured through improved casualty survival.

Prehospital blood transfusion programs: Capabilities and lessons learned.

The Trauma and Hemostasis Oxygenation Research (THOR) network has met in Bergen, Norway every summer over the past six years in an effort to have experts in transfusion, blood banking, military medicine, and trauma surgery exchange ideas, share their experiences, and set an agenda to move the science of remote damage control resuscitation forward. In this manuscript, we supply the lessons shared from the authors/speakers to the reader. These lessons include the experiences of the Norwegian Military with freeze dried plasma and whole blood resuscitation, lessons from extreme remote damage control resuscitation situations on oceanic cruises, and remote blood product resuscitation techniques at Mayo Clinic and the University of Pittsburgh.

Prehospital blood transfusions in pediatric trauma and nontrauma patients: a single-center review of safety and outcomes.

Prehospital transfusions are a novel yet increasingly accepted intervention in the adult population as part of remote damage control resuscitation, but prehospital transfusions remain controversial in children. Our purpose was to review our pediatric prehospital transfusion experience over 12years to describe the safety of prehospital transfusion in appropriately triaged trauma and nontrauma patients. Children (<18years) transfused with packed red blood cells (pRBC) or plasma during transport to a single regional academic medical center between 2002 and 2014 were identified. Admission details, in-hospital clinical course, and outcomes were analyzed. 28 children were transfused during transport; median age was 8.9±7years and 15 patients were male (54%). Most patients required at least one additional unit of blood products during their hospitalization (79%), and/or required operative intervention (53%), endoscopy (7%), or died during their hospitalization (14%). Comparison of trauma patients (n=16) and nontrauma patients (n=12) revealed that nontrauma patients were younger, more anemic, more coagulopathy on admission, and required more ongoing transfusion in the hospital. Trauma patients were more likely to need operative intervention. No patient had a transfusion reaction. Remote damage control prehospital transfusions of blood products were safe in this small group of appropriately triaged pediatric patients. Further studies are needed to determine if outcomes are improved and to devise a rigorous protocol for this prehospital intervention for critically ill pediatric patients.

Prehospital Blood Transfusion During Aeromedical Evacuation of Trauma Patients in Israel: The IDF CSAR Experience.

Data regarding the effect of prehospital blood administration to trauma patients during short-to-moderate time evacuations is scarce. The Israel Air Force Airborne Combat Search and Rescue is the only organization that deals with aeromedical evacuation for both military and civilian casualties in Israel and the only one with the ability to give blood in the prehospital setting. Data on packed red blood cells (PRBCs) administration in the evacuation missions from January 2003 to June 2010 were analyzed and actual transfusion practice was compared to clinical practice guidelines (CPGs). Over the studied 101 months, a total of 1,721 patients were evacuated by Combat Search and Rescue. Of these, 87 (5.1%) trauma patients were transfused with PRBC. Demographics included 83% male and 17% female with a median age of 23 years. Main mechanisms of injury included gunshot wounds (36%), motor vehicle accidents (28%), and blast injuries (24%) with an average of 2.6 injured regions per casualty. The most commonly injured body regions included lower extremities (52%), chest (45%), and abdomen (38%). Overall, 10 (11%) casualties died. Lifesaving intervention included tourniquets (27%), endotracheal intubation (24%), tube thoracostomy (24%), and needle thoracostomy (21%) times. For 98% of the patients, clinical judgment led to administration of red blood cells before indicated by the CPG. The heart rate tended to decrease during the evacuation, whereas there was no clear trend in systolic or diastolic blood pressure or shock index. In our aeromedical experience, transfusion of PRBCs for trauma patients was safe, feasible, and most likely beneficial. PRBCs were administered according to the flight surgeons' clinical judgment and not in complete adherence to CPGs in most cases. Data collected from this and similar studies worldwide have led to change in CPGs with the shift from hypertensive resuscitation to hypotensive-hemostatic Remote Damage Control Resuscitation.

Damage control surgery in weightlessness

Torso bleeding remains the most preventable cause of post-traumatic death worldwide. Remote damage control resuscitation (RDCR) endeavours to rescue the most catastrophically injured, but has not focused on prehospital surgical torso hemorrhage control (HC). We examined the logistics and metrics of intraperitoneal packing in weightlessness in Parabolic flight (0g) compared to terrestrial gravity (1g) as an extreme example of surgical RDCR. A surgical simulator was customized with high-fidelity intraperitoneal anatomy, a "blood" pump and flowmeter. A standardized HC task was to explore the simulator, identify "bleeding" from a previously unknown liver injury perfused at 80 mm Hg, and pack to gain hemostasis. Ten surgeons performed RDCR laparotomies onboard a research aircraft, first in 1g followed by 0g. The standardized laparotomy was sectioned into 20-second segments to conduct and facilitate parabolic flight comparisons, with "blood" pumped only during these time segments. A maximum of 12 segments permitted for each laparotomy. All 10 surgeons successfully performed HC in both 1g and 0g. There was no difference in blood loss between 1g and 0g (p = 0.161) or during observation following HC (p = 0.944). Compared to 1g, identification of bleeding in 0g incurred less "blood" loss (p = 0.032). Overall surgeons rated their personal performance and relative difficulty of surgery in 0g as "harder" (median Likert, 2/5). However, conducting all phases of HC were rated equivalent between 1g and 0g (median Likert, 3/5), except for instrument control (rated slightly harder, 2.75/5). Performing laparotomies with packing of a simulated torso hemorrhage in a high-fidelity surgical simulator was feasible onboard a research aircraft in both normal and weightless conditions. Despite being subjectively "harder," most phases of operative intervention were rated equivalently, with no statistical difference in "blood" loss in weightlessness. Direct operative control of torso hemorrhage is theoretically possible in extreme environments if logistics are provided.

Tactical Study of Care Originating in the Prehospital Environment (Tacscope)

Uncontrolled major hemorrhage and delayed evacuation remain substantial contributors to potentially survivable combat death, along with mission, environment, terrain, logistics, and hostile action. Life-saving interventions and the onset of acute traumatic coagulopathy (ATC) may also contribute. Analyze US casualty records from the DoD Trauma Registry, using International Normalized Ratio (INR) of 1.5 for onset of ATC. Retrospective cohort study from September 2007 to June 2011, inclusive. Independent variable was INR. Primary dependent variables were transfusion volume, massive transfusion (MT) defined as >10 units RBC/fresh whole blood in first 24 h, and 30-day survival. We used T test and chi-square analysis. Our IRB reviewed and exempted this study. In total, 8,913 cases were available. Fifty one percent had complete data with INR. Of excluded cases, 98.9% survived, average injury severity scales (ISS) was 7 (IQR 1-8), and less than 1% received MT. Among included cases, 98.5% survived, average ISS was 10 (IQR 2-14), average INR was 1.16 (CI95 1.14-1.17), and 2.7% received MT. There were 383 cases with ATC (8.4%). After stratification, we found that ATC cases were more likely to die (odds ratio (OR) 28, CI 16-48), receive MT (OR 9.6, CI 6.4-14.4), and were acidotic (pH 7.27 (7.24-7.31) vs. 7.38 (7.38-7.39)). Other significant differences included Injury Severity Score, Revised Trauma Score, blast mechanism, and penetrating injury. ATC is substantially associated with greater injury severity, MT, and mortality. Prehospital identification of MT casualties may expedite triage and evacuation, and enable remote damage control resuscitation to delay ATC onset and improve outcomes.

Coagulation factor concentrate-based therapy for remote damage control resuscitation (RDCR): a reasonable alternative?

The concept of remote damage control resuscitation (RDCR) is still in its infancy and there is significant work to be done to improve outcomes for patients with life-threatening bleeding secondary to injury. The prehospital phase of resuscitation is critical and if shock and coagulopathy can be rapidly minimized before hospital admission this will very likely reduce morbidity and mortality. The optimum transfusion strategy for these patients is still highly debated and the potential implications of the recently published pragmatic, randomize, optimal platelet, and plasma ratios trial (PROPPR) for RDCR have been reviewed. Identifying the appropriate transfusion strategy is mandatory before adopting prehospital hemostatic resuscitation strategies. An alternative approach is based on the early administration of coagulation factor concentrates combined with the antifibrinolytic tranexamic acid (TXA). The three major components to this approach in the context of RDCR target the following steps to achieve hemostasis: 1) stop (hyper)fibrinolysis; 2) support clot formation; and 3) increase thrombin generation. Strong evidence exists for the use of TXA. The data from the prospective fibrinogen in trauma induced coagulopathy (FIinTIC) study will inform on the prehospital use of fibrinogen in bleeding trauma patients. Deficits in thrombin generation may be addressed by the administration of prothrombin complex concentrates. Handheld point-of-care devices may be able to support and guide the prehospital and remote use of intravenous hemostatic agents including coagulation factor concentrates along with clinical presentation, assessment, and the extent of bleeding. Combinations may even be more effective for bleeding control. More studies are urgently needed.

"Blood failure" time to view blood as an organ: how oxygen debt contributes to blood failure and its implications for remote damage control resuscitation.

Hemorrhagic shock is both a local and systemic disorder. In the context of systemic effects, blood loss may lead to levels of reduced oxygen delivery (DO2 ) sufficient to cause tissue ischemia. Similar to other physiologic debts such as sleep, it is not possible to incur a significant oxygen debt and suffer no consequences for lack of timely repayment. While the linkage between oxygen debt and traditional organ failure (renal, hepatic, lung, and circulation) has been long recognized, we should consider failure in two additional linked and very dynamic organ systems, the endothelium and blood. These systems are very sensitive to oxygen debt and at risk for failing, having further implications on all other organ systems. The degree of damage to the endothelium is largely modulated by the degree of oxygen debt. Thus hypoperfusion is believed to begin a cascade of events leading to acute traumatic coagulopathy (ATC). This combination of oxygen debt driven endothelial damage and ATC might be considered collectively as "blood failure" due to the highly connected networks between these drivers. This article presents the implications of oxygen debt for remote damage control resuscitation strategies, such as permissive hypotension and hemostatic resuscitation. We review the impact of whole blood resuscitation and red blood cell efficacy in mitigation of oxygen debt. At last, this article recognizes the need for simple and durable, lightweight equipment that can detect the adequacy of tissue DO2 and thus patient needs for resuscitative care. Point-of-care lactate measuring may be a predictive tool for identifying high-risk trauma patients and occult shock because it provides information beyond that of vital signs and mechanism of injury as it may help predict the level of oxygen debt accumulation and need for resuscitation. Serial measurements may also be valuable as a tool in guiding resuscitative efforts.

The pragmatic randomized optimal platelet and plasma ratios trial: what does it mean for remote damage control resuscitation?

Implications from the pragmatic, randomize, optimal platelet and plasma ratios (PROPPR) trial are critical for remote damage control resuscitation (DCR). Utilizing DCR principals in remote settings can combat early mortality from hemorrhage. Identifying the appropriate transfusion strategy is mandatory prior to adopting prehospital hemostatic resuscitation strategies. The PROPPR study was examined in relation to the following questions: 1) Why is it important to have blood products in the prehospital setting?; 2) Which products should be investigated for prehospital hemostatic resuscitation?; 3) What is the appropriate ratio of blood product transfusion?; and 4) What are the appropriate indications for hemostatic resuscitation? PROPPR demonstrates that early and balanced blood product transfusion ratios reduced mortality in all patients at 3 hours and death from exsanguination at 24 hours (p = 0.03). The median time to death from exsanguination was 2.3 hours, highlighting the need for point-of-injury DCR capabilities. A 1:1:1 transfusion ratio of plasma:platelets:packed red blood cells increased the percentage of patients achieving anatomic hemostasis (p = 0.006). PROPPR used the assessment of blood consumption score to identify patients likely to require ongoing hemostatic resuscitation. The critical administration threshold predicted patient mortality and identified patients likely to require ongoing hemostatic resuscitation. A balanced resuscitation strategy demonstrates an early survival benefit, decreased death from exsanguination at 24 hours and a greater likelihood of achieving hemostasis in critically injured patients receiving a 1:1:1 ratio of plasma:platelets:PRBCs. This finding highlights the need to import DCR principals to remote locations.

Augmentation of point of injury care: Reducing battlefield mortality—The IDF experience

Study objectiveIn 2012, the Israel Defense Forces Medical Corps (IDF-MC) set a goal of reducing mortality and eliminating preventable death on the battlefield. A force buildup plan entitled “My Brother's Keeper” was launched addressing: trauma medicine, training, change of Clinical Practice Guidelines (CPGs), injury prevention, data collection, global collaboration and more. The aim of this article is to examine how military medical care has evolved due “My Brother's Keeper” between Second Lebanon War (SLW, 2006) to Operation Protective Edge (OPE, 2014). MethodsRecords of all casualties during OPE and SLW were extracted and analyzed from the I.D.F Trauma Registry. Noncombat injuries and civilian injuries from missile attacks were excluded from this analysis. ResultsThe plans main impacts were; incorporation of a physician or paramedic as an integral part of each fighting company, implementation of new CPGs, introduction of new approaches for extremity haemorrhage control and Remote Damage Control Resuscitation at point of injury (POI) using single donor reconstituted freeze dried plasma (25 casualties) and transexamic acid (98 casualties). During OPE, 704 soldiers sustained injuries compared with 833 casualties during SLW. Fatalities were 65 and 119, respectively, cumulating to Case Fatality Rate of 9.2% and 14.3%, respectively. ConclusionsSignificant changes in the way the IDF-MC provides combat casualty care have been made in recent years. It is the transformation from concept to doctrine and integration into a structured and Goal-Oriented Casualty Care System, especially POI care that led to the unprecedented survival rates in IDF as shown in this conflict.

Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting: A critical appraisal of the medical literature and available alternatives.

Hemorrhage remains the leading cause of preventable trauma-associated mortality. Interventions that improve prehospital hemorrhage control and resuscitation are needed. Tranexamic acid (TXA) has recently been shown to reduce mortality in trauma patients when administered upon hospital admission, and available data suggest that early dosing confers maximum benefit. Data regarding TXA implementation in prehospital trauma care and analyses of alternatives are lacking. This review examines the available evidence that would inform selection of hemostatic interventions to improve outcomes in prehospital trauma management as part of a broader strategy of "remote damage-control resuscitation" (RDCR). The medical literature available concerning both the safety and the efficacy of TXA and other hemostatic agents was reviewed. TXA use in surgery was studied in 129 randomized controlled trials, and a meta-analysis was identified. More than 800,000 patients were followed up in large cohort study. In trauma, a large randomized controlled trial, the CRASH-2 study, recruited more than 20,000 patients, and two cohort studies studied more than 1,000 war casualties. In the prehospital setting, the US, French, British, and Israeli militaries as well as the British, Norwegian, and Israeli civilian ambulance services have implemented TXA use as part of RDCR policies. Available data support the efficacy and the safety of TXA. High-level evidence supports its use in trauma and strongly suggests that its implementation in the prehospital setting offers a survival advantage to many patients, particularly when evacuation to surgical care may be delayed. TXA plays a central role in the development of RDCR strategies.