The Tägerwilen II report: Recommendations from the NATO Prehospital Care Improvement Initiative Task Force.

BACKGROUND: The Committee of the Chiefs of Military Medical Services (COMEDS) initiated the Prehospital Care Improvement Initiative Task Force (PHCII TF) to advise on how to improve prehospital care within NATO nations. The Task Force consisted of the NATO Military Health Care Working Group and its subordinated expert panels, including the Blood Panel, the Emergency Medicine Panel and the Special Operations Forces Medicine Panel. METHOD: The PHCII TF identified four key prehospital care themes for exploration: 1) Tactical Casualty Care, 2) Blood Far Forward), 3) Forward Surgical Capabilities), and 4) Prolonged Casualty Care. A consensus experimentation workshop explored the four themes, utilizing a modified Delphi technique and Utstein rotations during syndicate work, resulting in 83 consensus statements. The consensus statements were further evaluated on six criteria: actionable, measurable, urgent, interoperability, low risk/threat and impact. RESULTS: The 83 consensus statements, when weighted against the six criteria, resulted in 15 recommendations, focusing on standardization of training, ensuring provision of evidence-based practices and removing legislative barriers to improve prehospital care. CONCLUSION: The recommendations on these four themes reflect the most significant priorities in improving prehospital care, and must be incorporated in the on-going revision of NATO doctrine.

Transfusion practice in Central Norway - a regional cohort study in patients suffering from major haemorrhage.

BACKGROUND: In patients with major hemorrhage, balanced transfusions and limited crystalloid use is recommended in both civilian and military guidelines. This transfusion strategy is often applied in the non-trauma patient despite lack of supporting data. The aim of this study was to describe the current transfusion practice in patients with major hemorrhage of both traumatic and non-traumatic etiology in Central Norway, and discuss if transfusions are in accordance with appropriate massive transfusion protocols. METHODS: In this retrospective observational cohort study, data from four hospitals in Central Norway was collected from 01.01.2017 to 31.12.2018. All adults (≥18 years) receiving massive transfusion (MT) and alive on admission were included. MT was defined as transfusion of ≥10 units of packed red blood cells (PRBC) within 24 hours, or ≥ 5 units of PRBC during the first 3 hours after admission to hospital. Clinical data was collected from the hospital blood bank registry (ProSang) and electronic patient charts (CareSuite PICIS). Patients undergoing cardiothoracic surgery or extracorporeal membrane oxygenation treatment were excluded. RESULTS: A total of 174 patients were included in the study, of which 85.1% were non-trauma patients. Seventy-six per cent of all patients received plasma:PRBC in a ratio ≥ 1:2 (high ratio) and 59.2% of patients received platelets:PRBC in a ratio ≥ 1:2 (high ratio). 32.2% received a plasma:PRBC-ratio ≥ 1:1, and 23.6% platelet:PRBC-ratio ≥ 1:1. Median fluid infusion of crystalloids in all patients was 5750 mL. Thirty-seven per cent of all patients received tranexamic acid, 53.4% received calcium and fibrinogen concentrate was administered in 9.2%. CONCLUSIONS: Most patients had a non-traumatic etiology. The majority was transfused with high ratios of plasma:PRBC and platelet:PRBC, but not in accordance with the aim of the local protocol (1:1:1). Crystalloids were administered liberally for both trauma and non-trauma patients. There was a lower use of hemostatic adjuvants than recommended in the local transfusion protocol. Awareness to local protocol should be increased.

Management of COVID-19 in a Deployed Setting.

INTRODUCTION: Hamid Karzai International Airport is a NATO military base connected to the international airport in Kabul, Afghanistan. It is one of the larger NATO installations in Afghanistan, and with its location being one of the main hubs for international transit, the base has been at the frontline since the beginning of the COVID-19 pandemic. Hamid Karzai International Airport base commanders and medical staff have been at the forefront, continually developing policies and procedures to mitigate the pandemic in a deployed setting. MATERIAL AND METHODS: On base, approximately 4,000 people from 58 different nations lived within 0.5 km2. Diagnosis of COVID-19 was made by the detection of nucleic acid from the SARS-CoV-2 virus in nasopharyngeal/oropharyngeal swabs using real-time polymerase chain reaction (BioFire or GeneXpert). Serological tests (detecting IgM and IgG antibodies) were used as a screening tool. Data were reported from April 1 to September 12, 2020. RESULTS: Three thousand four hundred and sixty-six PCR tests were run in the reported period. Four hundred and seventy-eight positive cases were identified. Of these, only 106 reported symptoms. Seventy-eight presented spontaneously to the emergency room, while the remaining positive cases were identified as a result of aggressive testing of close contacts, base screening and surge testing. Twenty-two patients required oxygen treatment. One patient required mechanical ventilation and later died after strategic evacuation. DISCUSSION: Mitigation of COVID-19 was achieved by measures to reduce the spread of the virus, measures to reduce the population, and a medical response plan. To manage the logistic burden of isolating and quarantining a large portion of the population, a multinational and multidisciplinary COVID Task Force was formed. CONCLUSIONS: In a military population of mostly young and healthy individuals, the majority of COVID-positive patients will have fewer symptoms, and therefore, the aggressive screening of asymptomatic personnel is necessary. Outbreaks of COVID-19 in a military base could have a detrimental impact on missions but may be contained and controlled with quarantine, isolation, and aggressive contact tracing.

Is there a place for crystalloids and colloids in remote damage control resuscitation?

Crystalloids and colloids are used in prehospital fluid resuscitation to replace blood loss and preserve tissue perfusion until definite surgical control of bleeding can be achieved. However, large volumes of fluids will increase bleeding by elevating blood pressure, dislodging blood clots, and diluting coagulation factors and platelets. Hypotensive fluid resuscitation strategies are used to avoid worsening of uncontrolled bleeding. This is largely supported by animal studies. Most clinical evidence suggests that restricting fluid therapy is associated with improved outcome. Remote damage control resuscitation emphasizes the early use of blood products and restriction of other fluids to support coagulation and tissue oxygenation. Controversy regarding the optimal choice and composition of resuscitation fluids is ongoing. Compared with crystalloids, less colloid is needed for the same expansion of intravascular volume. On the other hand, colloids may cause coagulopathy not only related to dilution. The most important advantage of using colloids is logistical because less volume and weight are needed. In conclusion, prehospital fluid resuscitation is considered the standard of care, but there is little clinical evidence supporting the use of either crystalloids or colloids in remote damage control resuscitation. Alternative resuscitation fluids are needed.

Heat shock increases survival in rats exposed to hyperbaric pressure.

It has been shown that a single bout of exercise performed 20 hours prior to hyperbaric exposure reduces bubble formation and increases survival in rats. Heat shock proteins (HSPs) are stress proteins expressed in cells that are exposed to different stressors. HSPs are known to protect cells, by binding to proteins and stabilizing them. As it is known that a single bout of exercise induces HSPs, and that HSPs exert their protective effects 20-24 hours after the stimulus for induction, we hypothesized that HSPs might be one mechanism behind the observed exercise-induced protection. We hypothesized that rats that expressed HSPs would develop fewer bubbles and have a lower mortality than their non-stressed control group. Twenty-four female Sprague-Dawley rats (300-330 g) were divided into a heat-shock group and a control group and anaesthetized. The rats in the heat-shock group were heated to 42 ± 0.5 degrees Celsius for 15 min. The following day, all rats were compressed to 700 kPa for 45 min in a hyperbaric chamber. The right ventricles were insonated and bubbles were identified and graded. Six of 12 rats in the heat-shock group survive d, while 1 of 12 control rats survived (Chi square = 5.042, P = 0.034). There was no difference in bubble grade between the groups. The study suggests that the effect of heat shock on survival is not the same as observed after exercise, as the heat-shocked rats developed bubbles. However, heat shock appears to protect rats against the effects of bubbles by an independent mechanism.