ß-alanine supplementation improves tactical performance but not cognitive function in combat soldiers.

BACKGROUND: There are no known studies that have examined ß-alanine supplementation in military personnel. Considering the physiological and potential neurological effects that have been reported during sustained military operations, it appears that ß-alanine supplementation may have a potential benefit in maintaining physical and cognitive performance during high-intensity military activity under stressful conditions. The purpose of this study was to examine the effect of 28 days of ß-alanine ingestion in military personnel while fatigued on physical and cognitive performance. METHODS: Twenty soldiers (20.1 ± 0.9 years) from an elite combat unit were randomly assigned to either a ß-alanine (BA) or placebo (PL) group. Soldiers were involved in advanced military training, including combat skill development, navigational training, self-defense/hand-to-hand combat and conditioning. All participants performed a 4-km run, 5-countermovement jumps using a linear position transducer, 120-m sprint, a 10-shot shooting protocol with assault rifle, including overcoming a misfire, and a 2-min serial subtraction test to assess cognitive function before (Pre) and after (Post) 28 days of supplementation. RESULTS: The training routine resulted in significant increases in 4-km run time for both groups, but no between group differences were seen (p = 0.597). Peak jump power at Post was greater for BA than PL (p = 0.034), while mean jump power for BA at Post was 10.2% greater (p = 0.139) than PL. BA had a significantly greater (p = 0.012) number of shots on target at Post (8.2 ± 1.0) than PL (6.5 ± 2.1), and their target engagement speed at Post was also significantly faster (p = 0.039). No difference in serial subtraction performance was seen between the groups (p = 0.844). CONCLUSION: Results of this study indicate that 4-weeks of ß-alanine ingestion in young, healthy soldiers did not impact cognitive performance, but did enhance power performance, marksmanship and target engagement speed from pre-ingestion levels.

Injury patterns of soldiers in the second Lebanon war.

BACKGROUND: In the second Lebanon war in 2006, the Israeli Defense Forces fought against well-prepared and well-equipped paramilitary forces. The conflict took place near the Israeli border and major Israeli medical centers. Good data records were maintained throughout the campaign, allowing accurate analysis of injury characteristics. This study is an in-depth analysis of injury mechanisms, severity, and anatomic locations. METHODS: Data regarding all injured soldiers were collected from all care points up to the definitive care hospitals and were cross-referenced. In addition, trauma branch physicians and nurses interviewed medical teams to validate data accuracy. Injuries were analyzed using Injury Severity Score (ISS) (when precise anatomic data were available) and multiple injury patterns scoring for all. RESULTS: A total of 833 soldiers sustained combat-related injury during the study period, including 119 fatalities (14.3%). Although most soldiers (361) sustained injury only to one Abbreviated Injury Scale (AIS) region, the average number of regions per soldier was 2.0 but was 1.5 for survivors versus 4.2 for fatalities. CONCLUSION: Current war injury classifications have limitations that hinder valid comparisons between campaigns and settings. In addition, limitation on full autopsy in war fatalities further hinders data use. To partly compensate for those limitations, we have looked at the correlation between fatality rates and number of involved anatomic regions and found it to be strong. We have also found high fatality rates in some "combined" injuries such as head and chest injuries (71%) or in the abdomen and an extremity (75%). The use of multiinjury patterns analysis may help understand fatality rates and improve the utility of war injury analysis. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Prehospital injury severity of children evacuated by helicopters from combat zones: a retrospective report.

BACKGROUND: In Israel, the Airborne Rescue and Evacuation Unit (AREU) provides prehospital trauma care in times of peace and during times of armed conflict. In peacetime, the AREU transports children who were involved in motor vehicle collisions (MVC) and those who fall off cliffs (FOC). During armed conflict, the AREU evacuates children who sustain firearm injuries (FI) from the fighting zones. OBJECTIVE: To report on prehospital injury severity of children who were evacuated by the AREU from combat zones. METHODS: A retrospective comparative analysis was conducted on indicators of prehospital injury severity for patients who had MVC, FOC, and FI. It included the National Advisory Committee for Aeronautics (NACA) score, the Glasgow Coma Scale (GCS) score on scene, and the number of procedures performed by emergency medical personnel and by the AREU air-crew. RESULTS: From January 2003 to December 2009, 36 MVC, 25 FOC, and 17 FI children were transported from the scene by the AREU. Five patients were dead at the scene: 1 (2.8%) MVC, 1 (4%) FOC, and 3 (17.6%) FI. Two (11.7%) FI patients were dead on arrival at the hospital. MVC, FOC, and FI patients had mean (±SD) NACA scores of 4.4 ± 1.2, 3.6 ± 1.2, and 5 ± 0.7, respectively. Mean (±SD) GCS scores were 8.9 ± 5.6, 13.6 ± 4, and 6.9 ± 5.3, respectively. Life support interventions were required by 29 (80.6%) MVC, 3 (12%) FOC, and 15 (88.2%) FI patients. CONCLUSIONS: In the prehospital setting, children evacuated from combat zones were more severely injured than children who were transported from the scene during peacetime.

Triage and air evacuation strategy for mass casualty events: a model based on combat experience.

BACKGROUND: Management of combat casualties should optimize outcomes by appropriate patient triage, prehospital care, and rapid transport to the most capable medical facility, while avoiding overwhelming individual facilities. METHODS: Planning the medical support for the campaign was done by the medical department of the IDF Southern command in cohort with the medical department of the Homefront command. Data collection and analysis were done by the Trauma Branch of the Medical corp. RESULTS: 339 soldiers were injured, among them were 10 fatalities. Five hospitals received casualties, although the 2 regional hospitals received 84% of the primary evacuation load. The majority of urgently injured soldiers (90%) were evacuated by air, as opposed to 59% of non-urgently injured soldiers. CONCLUSIONS: In a cross border setting, airlifting the urgent casualties to farther away level I trauma centers provides appropriate care for them, while not crossing the "surge capacity" line for the near-by medical centers.

QuikClot Combat Gauze use for hemorrhage control in military trauma: January 2009 Israel Defense Force experience in the Gaza Strip--a preliminary report of 14 cases.

BACKGROUND: Standard gauze field dressings and direct pressure occasionally are inadequate for the control of hemorrhage. QuikClot® Combat Gauze™ (QCG) combines surgical gauze with an inorganic material and is approved by the Food and Drug Administration and by the Israeli Standards Institute for external hemorrhage control. The purpose of this article is to report clinical use of this dressing during Operation Cast Lead in the Gaza strip during January 2009. METHODS: QuikClot Combat Gauze and the QCG guidelines were issued to advanced life support (ALS) providers during the preparations for the Operation. All cases of injuries involving hemorrhage were reviewed, as well as interviews with the ALS providers (physicians and paramedics) and injured soldiers. RESULTS: Fourteen uses of QCG were reported and reviewed (out of a total of 56 hemostatic interventions in 35 cases). Dressings were applied to injuries to the head, neck, axilla, buttocks, abdomen, back, and pelvis in 10 cases, and to extremities in four cases. In 13 cases (93%), injuries were caused by blast or gunshot mechanisms. The success rate was reported as 79% (11/14). Failure to control hemorrhage was reported in three cases in three different locations: neck, buttock, and thigh. All failures were attributed to severe soft tissue and vascular injuries. No complications or adverse events were reported. CONCLUSIONS: This report on the clinical field use of the QCG dressing by ALS providers suggests that it is an effective and safe product, and applicable for prehospital treatment of combat casualties. This report further suggests that QCG should be issued to medics as well as ALS providers. Larger clinical investigations are needed to confirm these findings.

Anatomic distribution of bullet head injuries in combat fatalities.

BACKGROUND: Gun-shot wound head injury comprises a substantial fraction of combat injuries and a major cause of death in the battlefield. Current shielding gear is totally ineffective against bullets, because bullet-proof materials are too heavy to be worn on the head. The aim of this work was to describe the anatomic distribution of bullet entry wounds to the head in combat fatalities and to discern whether distribution is random (null hypothesis) or not. METHODS: We retrospectively examined the forensic external examination reports of all Israeli Defense Forces combat fatalities during the years 2000 to 2004, the Second Lebanon War (2006), and Operation Cast Lead (2009) and mapped the exact anatomic location of all bullet entry wounds to the calvaria. RESULTS: We found 76 gun-shot entry wounds to the heads of 49 fatalities. Among these wounds, the occipital and anterior-temporal regions were found to be hit significantly more often than expected compared with their relative surface area (p < 0.001 and p < 0.001, respectively). Fifty-five percent of all injuries occurred within 15% of the surface area of skull. CONCLUSIONS: These findings imply that gun-shot entry wounds to the head are unevenly distributed. A partially bullet-proof protective helmet may prevent a substantial fraction of injuries (and fatalities) without a significant weight addition to the helmet.