The Use of Intravenous Lidocaine as an Analgesic Modality in the Austere Environment: Two Cases.

Providing effective analgesia for trauma in austere settings is particularly difficult and often complicated by equipment and medication limitations and harsh environmental conditions. Common modalities that are employed in conventional clinical practices may not be available or pragmatic in austere environments. Furthermore, side effects such as sedation, altered mentation, or hypoxemia require additional resources and attention. We report 2 cases that demonstrate the use of intravenous lidocaine for the management of acute pain, secondary to trauma, in an austere environment. In the first, the administration of intravenous lidocaine reduced pain, secondary to a tibia fracture, thereby facilitating splinting. In the second, a patient, who had sustained rib fractures, was also treated with intravenous lidocaine. In this case, the analgesic effects of the medication resulted in reduction in pain and improvement in pulmonary function. Of note, the narrow therapeutic window of this modality was made evident as both patients transiently experienced tinnitus following the initial lidocaine bolus. This report describes 2 cases in which intravenous lidocaine was used to manage acute pain, in an austere environment, while avoiding many of the detrimental effects that accompany alternative analgesics.

Risk Associated With Autologous Fresh Whole Blood Training.

Fresh whole blood (FWB) is increasingly being recognized as the ideal resuscitative fluid for hemorrhagic shock. Because of this, military units are working to establish the capability to give FWB from a walking blood bank donor in environments that are unsupported by conventional blood bank services. Therefore, many military units are performing autologous blood transfusion training. In this training, a volunteer has a unit of blood collected and then transfused back into the same donor. The authors report their experience performing an estimated 3408 autologous transfusions in training and report no instances of hemolytic transfusion reactions or other major complications. With appropriate control measures in place, autologous FWB training is low-risk training.

Improvised Inguinal Junctional Tourniquets: Recommendations From the Special Operations Combat Medical Skills Sustainment Course.

Effectively and rapidly controlling significant junctional hemorrhage is an important effort of Tactical Combat Casualty Care (TCCC) and can potentially contribute to greater survival on the battlefield. Although the US Food and Drug Administration (FDA) has approved labeling of four devices for use as junctional tourniquets, many Special Operations Forces (SOF) medics do not carry commercially marketed junctional tourniquets. As part of ongoing educational improvement during Special Operations Combat Medical Skills Sustainment Courses (SOCMSSC), the authors surveyed medics to determine why they do not carry commercial tourniquets and present principles and methods of improvised junctional tourniquet (IJT) application. The authors describe the construction and application of IJTs, including the use of available pressure delivery devices and emphasizing that successful application requires sufficient and repetitive training.

Optimization of Simulation and Moulage in Military-Related Medical Training.

Preparation of Special Operations Forces (SOF) Medics as first responders for the battle space and austere environments is critical to optimize survival and quality of life for our Operators who may sustain serious and complex wounding patterns and illnesses. In the absence of constant clinical exposure for these medics, it is necessary to maximize all available training opportunities. The incorporation of scenario-based training helps weave together teamwork and the ability to practice treatment protocols in a tactical, controlled training environment to reproduce, to some degree, the environment in and stressors under which care will need to be delivered. We reviewed the evolution of training scenarios within one Pararescue (PJ) team since 2008 and codified various tools used to simulate physical findings and drive medical exercises as part of scenario-based training. We also surveyed other SOF Medic training resources.

TCCC Guidelines Comprehensive Review and Update: TCCC Guidelines Change 16-03.

Based on careful review of the Tactical Combat Casualty Care (TCCC) Guidelines, the authors developed a list of proposed changes for inclusion in a comprehensive change proposal. To be included in the proposal, individual changes had to meet at least one of three criteria: (1) The change was primarily tactical rather than clinical; (2) the change was a minor modification to the language of an existing TCCC Guideline; and (3) the change, though clinical, was straightforward and noncontentious. The authors presented their list to the TCCC Working Group for review and approval at the 7 September 2016 meeting of the Committee on Tactical Combat Casualty Care (CoTCCC). Twenty-three items met with general agreement and were retained in this change proposal.

Volumetric control of whole blood collection in austere environments.

INTRODUCTION: Fresh whole blood transfusions are a powerful tool in prehospital care; however, the lack of equipment such as a scale in field situations frequently leads to collections being under- or overfilled, leading to complications for both patient and physician. This study describes two methods for simple, rapid control of collection bag volume: (1) a length of material to constrict the bag, and (2) folding/clamping the bag. METHOD: Whole blood collection bags were allowed to fill with saline via gravity. Paracord, zip-tie, beaded cable tie, or tourniquet was placed around the bag at circumferences of 6 to 8.75 inches. A hemostat was used to clamp folds of 1 to 1.5 inches. Several units were drawn during training exercises of the 75th Ranger Regiment with volume controlled by three methods: vision/touch estimation, constriction by paracord, and clamping with hemostat. RESULTS: Method validation in the Terumo 450-mL bag indicated that paracord, zip-tie, and beaded cable tie lengths of 6.5 inches or clamping 1.25 inches with a hemostat provided accurate filling. The volume variance was significantly lower when using the beaded cable tie. Saline filling time was approximately 2 minutes. With the Fenwal 450-mL bag, the beaded cable tie gave best results; even if incorrectly placed by one/two beads, the volume was still within limits. In training exercises, the use of the cord/clamp greatly reduced the variability; more bags were within limits. CONCLUSIONS: Both constricting and clamping allow for speed and consistency in blood collection. The use of common cord is appealing, but knot tying induces inevitable variability; a zip/cable tie is easier. Clamping was quicker but susceptible to high variance and bag rupturing. With proper methodological training, appropriate volumes can be obtained in any environment with minimal tools. LEVEL OF EVIDENCE: Therapeutic/care management study, level IV.

Fresh Whole Blood transfusions in the austere environment.

The use of Fresh Whole Blood (FWB) transfusions can be a powerful tool for the Special Operations Forces (SOF) medic to treat uncontrolled hemorrhage. In fact, it may be the only tool currently available for hemostatic resuscitation, which along with hypotensive resuscitation, forms the basis for Damage Control Resuscitation (DCR). Until now, no comprehensive protocol has existed for conducting FWB transfusions in austere environments. The United States Special Operations Command (USSOCOM) sponsored Curriculum Evaluation Board (CEB), which is responsible for authoring the Tactical Emergency Medical Protocols (TMEPs) has produced a protocol. This article serves as its introduction.