Emergency Resuscitative Thoracotomy in the Combat or Operational Environment.

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.

Management of Open Pneumothorax in Tactical Combat Casualty Care: TCCC Guidelines Change 13-02.

During the recent United States Central Command (USCENTCOM) and Joint Trauma System (JTS) assessment of prehospital trauma care in Afghanistan, the deployed director of the Joint Theater Trauma System (JTTS), CAPT Donald R. Bennett, questioned why TCCC recommends treating a nonlethal injury (open pneumothorax) with an intervention (a nonvented chest seal) that could produce a lethal condition (tension pneumothorax). New research from the U.S. Army Institute of Surgical Research (USAISR) has found that, in a model of open pneumothorax treated with a chest seal in which increments of air were added to the pleural space to simulate an air leak from an injured lung, use of a vented chest seal prevented the subsequent development of a tension pneumothorax, whereas use of a nonvented chest seal did not. The updated TCCC Guideline for the battlefield management of open pneumothorax is: ?All open and/ or sucking chest wounds should be treated by immediately applying a vented chest seal to cover the defect. If a vente chest seal is not available, use a non-vented chest seal. Monitor the casualty for the potential development of a subsequent tension pneumothorax. If the casualty develops increasing hypoxia, respiratory distress, or hypotension and a tension pneumothorax is suspected, treat by burping or removing the dressing or by needle decompression.? This recommendation was approved by the required two-thirds majority of the Committee on TCCC in June 2013.

Ultrasound evaluation of cranial and long bone fractures in a cadaver model.

BACKGROUND: Ultrasound has been utilized in various settings for evaluation and treatment of skeletal injuries. Bone has different tissue acoustic impedance than soft tissue allowing visualization of the cortical disruption found in fractures. OBJECTIVE: To determine emergency physicians' accuracy in diagnosing cranial and long bone fractures using ultrasound. METHODS: This multi-center prospective double-blinded study used high-frequency linear ultrasound to detect induced fractures among eight test locations from eight cadaver models. After a standard orientation, blinded emergency physicians interpreted real-time sonographic images of test locations. RESULTS: Proximal tibia combined sensitivity (SE)/specificity (SP) was 87.3/69.8% with a combined positive predictive value (PPV)/negative predictive value (NPV) of 84.6/74.3%. Distal radius combined SE/SP was 93.7/93.5% with a combined PPV/NPV of 93.4/90.8%. Frontal combined SE/SP was 84.1/88.9% with a PPV/NPV of 84.9/88.3%. Temporal-parietal combined SE/SP was 95.2/87.9% with a PPV/NPV of 94.8/88.2%. Time to decision varied from less than 10 seconds to 357 seconds. Mean time to decision was 43 to 63 seconds depending on fracture site. CONCLUSION: Ultrasound by trained emergency medicine physicians can reliably identify fractures in the radius, tibia, frontal, and temporal bones in a very short amount of time, allowing for triage, treatment, and resource management.