Fluid Resuscitation for Hemorrhagic Shock in Tactical Combat Casualty Care: TCCC Guidelines Change 14-01--2 June 2014.

This report reviews the recent literature on fluid resuscitation from hemorrhagic shock and considers the applicability of this evidence for use in resuscitation of combat casualties in the prehospital Tactical Combat Casualty Care (TCCC) environment. A number of changes to the TCCC Guidelines are incorporated: (1) dried plasma (DP) is added as an option when other blood components or whole blood are not available; (2) the wording is clarified to emphasize that Hextend is a less desirable option than whole blood, blood components, or DP and should be used only when these preferred options are not available; (3) the use of blood products in certain Tactical Field Care (TFC) settings where this option might be feasible (ships, mounted patrols) is discussed; (4) 1:1:1 damage control resuscitation (DCR) is preferred to 1:1 DCR when platelets are available as well as plasma and red cells; and (5) the 30-minute wait between increments of resuscitation fluid administered to achieve clinical improvement or target blood pressure (BP) has been eliminated. Also included is an order of precedence for resuscitation fluid options. Maintained as recommendations are an emphasis on hypotensive resuscitation in order to minimize (1) interference with the body's hemostatic response and (2) the risk of complications of overresuscitation. Hextend is retained as the preferred option over crystalloids when blood products are not available because of its smaller volume and the potential for long evacuations in the military setting.

Closing the "care in the air" capability gap for severe lung injury: the Landstuhl Acute Lung Rescue Team and extracorporeal lung support.

BACKGROUND: The success of US Air Force Critical Care Air Transport Teams (CCATT) in transporting critically ill and injured patients enabled changes in military medical force deployment and casualty care practice. Even so, a subset of casualties remains who exceed even CCATT capabilities for movement. These patients led to the creation of the Landstuhl Acute Lung Rescue Team (ALeRT) to close the "care in the air" capability gap. METHODS: The ALeRT Registry was queried for the period between November 1, 2005, and June 30, 2010. Additionally, Landstuhl Regional Medical Center critical care patient transfers to host nation medical centers were reviewed for cases using extracorporeal lung support systems. RESULTS: For the review period, US Central Command activated the ALeRT on 40 occasions. The ALeRT successfully evacuated patients on 24 of 27 missions launched (89%). Three patients were too unstable for ALeRT evacuation. Of the 13 remaining activations, four patients died and nine patients improved sufficiently for standard CCATT movement. The ALeRT initiated pumpless extracorporeal lung assistance six times, but only once to facilitate evacuation. Two patients were supported with full extracorporeal membrane oxygenation support after evacuation due to progressive respiratory failure. CONCLUSIONS: ALeRT successfully transported 24 casualties from the combat zones to Germany. Without the ALeRT, these patients would have remained in the combat theater as significant consumers of limited deployed medical resources. Pumpless extracorporeal lung assistance is already within the ALeRT armamentarium, but has only been used for one aeromedical evacuation. Modern extracorporeal membrane oxygenation systems hold promise as a feasible capability for aeromedical evacuation.

Intercontinental aeromedical evacuation of patients with traumatic brain injuries during Operations Iraqi Freedom and Enduring Freedom.

Traumatic brain injury contributes significantly to military combat morbidity and mortality. No longer maintaining comprehensive medical care facilities throughout the world, the US military developed a worldwide trauma care system making the patient the moving part of the system. Life-saving interventions are performed early, and essential care is delivered at forward locations. Patients then proceed successively through increasingly capable levels of care culminating with arrival in the US. Proper patient selection and thorough mission preparation are crucial to the safe and successful intercontinental aeromedical evacuation of critical brain-injured patients during Operations Iraqi Freedom and Enduring Freedom.

Traumatic brain injury and aeromedical evacuation: when is the brain fit to fly?

BACKGROUND: To review the inflammatory sequelae of traumatic brain injury (TBI) and altitude exposure and discuss the potential impact of aeromedical evacuation (AE) on this process. METHODS: Literature review and expert opinion regarding the inflammatory effects of TBI and AE. RESULTS: Traumatic brain injury has been called the signature injury of the current military conflict. As a result of the increasing incidence of blast injury, TBI is responsible for significant mortality and enduring morbidity in injured soldiers. Common secondary insults resulting from post-traumatic cerebral inflammation are recognized to adversely impact outcome. AE utilizing Critical Care Air Transport Teams has become a standard of care practice following battlefield injury, to quickly and safely transport critically injured soldiers to more sophisticated echelons of care. Exposure to the hypobaric conditions of the AE process may impose an additional physiologic risk on the TBI patient as well as a "second hit" inflammatory stimulus. CONCLUSIONS: We review the known inflammatory effects of TBI and altitude exposure and propose that optimizing the post-traumatic inflammatory profile may assist in determining an ideal time to fly for head-injured soldiers.

Air transport of patients with severe lung injury: development and utilization of the Acute Lung Rescue Team.

BACKGROUND: Critical Care Air Transport Teams (CCATTs) are an integral component of modern casualty care, allowing early transport of critically ill and injured patients. Aeromedical evacuation of patients with significant pulmonary impairment is sometimes beyond the scope of CCATT because of limitations of the transport ventilator and potential for further respiratory deterioration in flight. The Acute Lung Rescue Team (ALRT) was developed to facilitate transport of these patients out of the combat theater. METHODS: The United States TRANSCOM Regulation and Command/Control Evacuation System and the United States Army Institute of Surgical Research Joint Theater Trauma Registry databases were reviewed for all critical patients transported out of theater between November 2005 and March 2007. Patient demographics, diagnosis, and clinical history were abstracted and ALRT patients were compared with CCATT patients. RESULTS: The ALRT was activated for 11 patients during the study period. Five patients were transported as a result of these activations. Trauma-related diagnoses were responsible for 82% of these requests. ALRT missions comprised 0.6% of all critical patient movements out of the combat theater and 1% of ventilator transports. Average FIO2 was 0.92 +/- 0.11 for ALRT patients and 0.53 +/- 0.14 for CCATT patients (p = 0.005). ALRT patients required a mean positive end expiratory pressure of 19.0 cm H2O +/- 2.2 cm H2O compared with 6.5 cm H2O +/- 2.4 cm H2O in the CCATT group (p = 0.002). CONCLUSIONS: Lung injury in the combat theater severe enough to exceed the capability of CCATT transport is uncommon. Patients for whom ALRT was activated had significantly higher positive end expiratory pressure and FIO2 than those transported by CCATT. One-fourth of patients for whom ALRT was considered died before the team could be launched; transport may have been a futile consideration in these patients. Patients with even severe acute respiratory distress syndrome can be successfully transported by experienced, equipped specialty teams.

Critical care at Landstuhl Regional Medical Center.

BACKGROUND: Landstuhl Regional Medical Center is the largest U.S. medical facility outside the United States, and it is the first permanently positioned hospital outside the combat zone providing care to the wartime sick and wounded. As of November 2007, Landstuhl Regional Medical Center personnel have treated over 45,000 patients from Operations Enduring Freedom and Iraqi Freedom. The current trauma/critical care service is a multidisciplinary, intensivist-directed team caring for a diverse range of clinical diagnoses to include battle injuries, diseases, and nonbattle injuries. Admissions arise from an at-risk population of 500,000 widely distributed over a geographic area encompassing three continents. DISCUSSION: When compared with 2001, the average daily intensive care unit census has tripled and the patient acuity level has doubled. Combat casualties account for 85% of service admissions. The clinical practice at this critical care hub continues to evolve as a result of wartime damage control trauma care, robust critical care air transport capabilities, length of stay, and other unique factors. The service's focus is to optimize patients for an uneventful evacuation to the United States for definitive care and family support. SUMMARY: Successful verification in 2007 as an American College of Surgeons level II trauma center reflects a continuing institutional commitment to providing the best possible care to the men and women serving our nation in the global war on terror.

Evaluation of trauma team performance using an advanced human patient simulator for resuscitation training.

BACKGROUND: Human patient simulation (HPS) has been used since 1969 for teaching purposes. Only recently has technology advanced to allow application to the complex field of trauma resuscitation. The purpose of our study was to validate an advanced HPS as an evaluation tool of trauma team resuscitation skills. METHODS: The pilot study evaluated 10 three-person military resuscitation teams from community hospitals that participated in a 28-day rotation at a civilian trauma center. Each team consisted of physicians, nurses, and medics. Using the HPS, teams were evaluated on arrival and again on completion of the rotation. In addition, the 10 trauma teams were compared with 5 expert teams composed of experienced trauma surgeons and nurses. Two standardized trauma scenarios were used, representing a severely injured patient with multiple injuries and with an Injury Severity Score of 41 (probability of survival, 50%). Performance was measured using a unique human performance assessment tool that included five scored and eight timed tasks generally accepted as critical to the initial assessment and treatment of a trauma patient. Scored tasks included airway, breathing, circulation, and disability assessments as well as overall organizational skills and a total score. The nonparametric Wilcoxon test was used to compare the military teams' scores for scenarios 1 and 2, and the comparison of the military teams' final scores with the expert teams. A value of p < 0.05 was considered significant. RESULTS: The 10 military teams demonstrated significant improvement in four of the five scored (p < or = 0.05) and six of the eight timed (p < or = 0.05) tasks during the final scenario. This improvement reflects the teams' cumulative didactic and clinical experience during the 28-day trauma refresher course as well as some degree of simulator familiarization. Improved final scores reflected efficient and coordinated team efforts. The military teams' initial scores were worse than the expert group in all categories, but their final scores were only lower than the expert groups in 2 of 13 measurements (p < or = 0.05). CONCLUSION: No studies have validated the use of the HPS as an effective teaching or evaluation tool in the complex field of trauma resuscitation. These pilot data demonstrate the ability to evaluate trauma team performance in a reproducible fashion. In addition, we were able to document a significant improvement in team performance after a 28-day trauma refresher course, with scores approaching those of the expert teams.