Association of Prehospital Neck Wound Survivability and Battlefield Medical Evacuation Time in Afghanistan.

INTRODUCTION: The U.S. Military's Golden Hour policy led to improved warfighter survivability during the Global War on Terror. The policy's success is well-documented, but a categorical evaluation and stratification of medical evacuation (MEDEVAC) times based on combat injury is lacking. METHODS: We queried the Department of Defense Joint Trauma System Prehospital Trauma Registry for casualties with documented penetrating neck trauma in Afghanistan requiring battlefield MEDEVAC from June 15, 2009, through February 1, 2021. Casualties were excluded if the time from the point of injury to reach higher level medical care was not documented, listed as zero, or exceeded 4 hours. They were also excluded if demographic data were incomplete or deemed unreliable or if their injuries occurred outside of Afghanistan.We designed a logistic regression model to test for associations in survivability, adjusting for composite injury severity score, patient age group, and type of next higher level of care reached. We then used our model to interpolate MEDEVAC times associated with 0.1%, 1%, and 10% increased risk of death for an incapacitated casualty with penetrating neck trauma. RESULTS: Of 1,147 encounters, 444 casualties met inclusion criteria. Of these casualties, 430 (96.9%) survived to discharge. Interpolative analysis of our multivariable logistic regression model showed that MEDEVAC times ≥8 minutes, ≥53 minutes, and ≥196 minutes are associated with a 0.1%, 1%, and 10% increased risk of mortality from baseline, respectively. CONCLUSIONS: Our data characterize the maximum MEDEVAC times associated with 0.1%, 1%, and 10% increased risk of death from baseline survivability for penetrating battlefield neck trauma in Afghanistan.

Market Analysis of Video Laryngoscopy Equipment for the Role 1 Setting.

INTRODUCTION: Airway compromise is the second leading cause of potentially preventable prehospital combat death. Endotracheal intubation (ETI) remains the most common role 1 airway intervention. Video laryngoscopy (VL) is superior to direct laryngoscopy (DL) for first-attempt intubation, especially in less-experienced providers and for trauma patients. The cost has been a major challenge in pushing VL technology far-forward; however, the cost of equipment continues to become more affordable. We conducted a market analysis of VL devices under $10,000 for possible options for role 1. MATERIALS AND METHODS: We searched Google, PubMed, and the Food and Drug Administration database from August 2022 to January 2023 with a combination of several keywords to identify current VL market options under $10,000. After identifying relevant manufacturers, we then reviewed individual manufacturer or distributor websites for pricing data and system specifications. We noted several characteristics regarding VL device design for comparison. These include monitor features, size, modularity, system durability, battery life, and reusability. When necessary, we requested formal price quotes from respective companies. RESULTS: We identified 17 VL options under $10,000 available for purchase, 14 of which were priced below $5,000 for individual units. Infium (n = 3) and Vimed Medical (n = 4) provided the largest number of unique models. VL options under $10,000 exist in both reusable and disposable modalities. These modalities included separate monitors as well as monitors attached to the VL handle. Disposable options, on a per-unit basis, cost less than reusable options. CONCLUSIONS: Several VL options exist within our goal price point in both reusable and disposable options. Clinical studies assessing the technology performance of ETI and deliberate downselection are needed to identify the most cost-effective solution for role 1 dispersion.

Lessons from the Fallen: An After-Action Review of Prehospital Casualty Data during the Global War on Terror.

BACKGROUND: The US military's recent involvement in long standing conflict has caused the pioneering of many lifesaving medical advances, often made possible by data-driven research. However, future advances in battlefield medicine will likely require greater data fidelity than is currently attainable. Continuing to improve survival rates will require data which establishes the relative contributions to preventable mortality and guides future interventions. Prehospital data, particularly that from Tactical Combat Casualty Care (TCCC) Cards and TCCC After Action Reports (TCCC AARs), are notoriously inconsistent in reaching searchable databases for formal evaluation. While the military has begun incorporating more modern technology in advanced data capture over the past few years like the Air Force's Battlefield Assisted Trauma Distributed Observation Kit (BATDOK) and the Army's Medical Hands-free Unified Broadcast system (MEDHUB), more analysis weighing the advantages and disadvantages of substituting analog solutions is needed. DISCUSSION: We propose 3 changes which may aid prehospital data capture and facilitate analysis: reexamine the current format of TCCC Cards and consider reducing the number of available datapoints to streamline completion, implement a military-wide mandate for all Role 1 providers to complete a TCCC AAR within 24 hours of a casualty event, and formalize the process of requesting de-identified data from the Armed Forces Medical Examiner System (AFMES) database. CONCLUSION: Reflecting on the state of US military medicine after 20 years of war, an important focus is improving the way prehospital data is gathered and analyzed by the military. There are steps we can take now to enhance our capabilities.

Prehospital Pharmacotherapy in Moderate and Severe Traumatic Brain Injury: A Systematic Review.

BACKGROUND: Traumatic brain injury (TBI) affects civilian and military populations with high morbidity and mortality rates and devastating sequelae. As the US military shifts its operational paradigm to prepare for future large-scale combat operations, the need for prolonged casualty care is expected to intensify. Identifying efficacious prehospital TBI management strategies is therefore vital. Numerous pharmacotherapies are beneficial in the inpatient management of TBI, including beta blockers, calcium channel blockers, statins, and other agents. However, their utility in prehospital management of moderate or severe TBI is not well understood. We performed a systematic review to elucidate agents of potential prehospital benefit in moderate and severe TBI. METHODS: We searched 6 databases from January 2000 through December 2021 without limitations in outcome metrics using a variety of search terms designed to encapsulate all studies pertaining to prehospital TBI management. We identified 2,142 unique articles, which netted 114 studies for full review. Seven studies met stringent inclusion criteria for our aims. RESULTS: Studies meeting inclusion criteria assessed tranexamic acid (TXA) (n=6) and ethanol (n=1). Of the TXA studies, 3 were randomized controlled trials, 2 were retrospective cohort studies, 1 was a prospective cohort study, and 1 was a meta-analysis. Notably absent were papers investigating therapeutics shown to be beneficial in inpatient hospital treatment of TBI. Overall, data suggest TXA administration is potentially beneficial in moderate or severe TBI with or without intracranial hemorrhage. Severe TBI with or without penetrating trauma was associated with worse overall outcomes, regardless of TXA use. CONCLUSION: Effective interventions for treating moderate or severe TBI are lacking. TXA is the most widely studied pharmacologic intervention and appears to offer some benefit without adverse effects in moderate TBI (with or without intracranial hemorrhage) in the pre-hospital setting despite heterogeneous results. Limitations of these studies include heterogeneity in outcome metrics, patient populations, and circumstances of TXA use. We identified a gap in the literature in translating agents with demonstrated inpatient benefit to the prehospital setting. Further investigation into these and other novel therapeutic options in the prehospital arena is crucial to improving clinical outcomes in TBI.

Blood Product Administration During the Role 1 Phase of Care: The Prehospital Trauma Registry Experience.

BACKGROUND: The majority of combat deaths occur in the prehospital setting. Efforts to increase survival including blood transfusions are made in the prehospital setting. The blood products available in the Role 1 setting include whole blood (WB), red blood cells (RBCs), fresh frozen plasma (FFP), and lyophilized (freeze-dried) plasma (FDP). METHODS: This is a secondary analysis of a previously published dataset within the Prehospital Trauma Registry (PHTR) from 2003 through May 2019. Deterministic linking was used when possible with the DoD Trauma Registry for outcome data. Descriptive statistics were used to analyze the data. RESULTS: We identified 1,357 patient encounters in the PHTR. Within that group, 28 patients received a prehospital blood product, with 41 total administrations: WB (18), RBCs (12), FFP (6), FDP (3), and blood not otherwise specified (2). Outcome data were available for 17 of the 28 patients. The median injury severity score was 20, with the thorax being the most frequent seriously injured body region. Most (94%) patients survived to discharge. The median ICU days was 11 (Interquartile Range [IQR] 3-19), and the median hospital days was 19 (IQR 8-29). The average volume (units) of RBCs was 6.0 (95% CI 1.9-10.1), WB 2.8 (95% CI 0.0-5.6), platelets 0.7 (95% CI 0.0-1.4), and FFP 5.0 (95% CI 1.2-8.8). CONCLUSIONS: The use of prehospital blood products is uncommon in U.S. combat settings. Patients who received blood products sustained severe injuries but had a high survival rate. Given the infrequent but critical use and potentially increased need for adequate prolonged casualty care in future near-peer conflicts, optimizing logistical chain circulation is required.

Characterizing pediatric supermassive transfusion and the contributing injury patterns in the combat environment.

BACKGROUND: Trauma is the leading cause of pediatric mortality in the United States. Often, these patients require supermassive transfusion (SMT), which we define as receipt of >80 mL/kg blood products, double the proposed volume for standard pediatric massive transfusion (MT). Evaluating the blood volumes, injury patterns, clinical findings, and prehospital interventions predictive for SMT are critical to reducing pediatric mortality. We describe the pediatric casualties, injury patterns, and clinical findings that comprise SMT. METHODS: We retrospectively analyzed pediatric trauma data from the Department of Defense Trauma Registry from January 2007-2016. We stratified patients into two cohorts based on blood products received in the first 24 h after injury: 1) those who received 40-80 mL/kg (MT), or 2) those who received >80 mL/kg (SMT). We evaluated demographics, injury patterns, prehospital interventions, and clinical findings. RESULTS: Our original dataset included 3439 pediatric casualties. We identified 536 patients who met inclusion parameters (receipt of ≥40 mL/kg of blood products [whole blood, packed red blood cells, fresh frozen plasma, platelets, or cryoprecipitate]). The MT cohort included 271 patients (50.6%), and the SMT cohort comprised 265 patients (49.4%). Survival to discharge was significantly lower (78% for SMT, 86% for MT; p < 0.011) in the SMT cohort. Multivariable analysis of injury patterns revealed serious injuries (Abbreviated Injury Scale 3-6) to the extremities (OR 2.13, 95% CI 1.45-3.12) and abdomen (OR 1.65, 1.08-2.53) were associated with SMT. Wound dressings (41% versus 29%; p = 0.003), tourniquets (23% vs 12%; p = 0.001), and IO access (17% vs 10%; p = 0.013) were more common in the SMT group. Age-adjusted hypotension was significantly higher in the SMT group (41%, n = 100 vs 23%, n = 59; p < 0.001) with no statistical difference detected in tachycardia (87%, n = 223 vs 87%, n = 228; p = 0.932). CONCLUSIONS: Our research demonstrates that pediatric SMT patients are at increased risk of mortality. Our study highlights the seriousness of extremity injuries in pediatric trauma patients, identifying associations between severe injuries to the extremities and abdomen with the receipt of SMT. Prehospital interventions of wound dressing, tourniquets, and IO access were more frequent in the SMT cohort. Our research determined that hypotension was associated with SMT, but tachycardia was not a reliable predictor of SMT over MT.

A Descriptive Analysis of Battlefield First Responder and Combat Lifesaver Interventions during the Role 1 Phase of Care.

BACKGROUND: Battlefield first responders (BFR) are the first non-medical personnel to render critical lifesaving interventions for combat casualties, especially for massive hemorrhage where rapid control will improve survival. Soldiers receive medical instruction during initial entry training (IET) and unit-dependent medical training, and by attending the Combat Lifesaver (CLS) course. We seek to describe the interventions performed by BFRs on casualties with only BFRs listed in their chain of care within the Prehospital Trauma Registry (PHTR). METHODS: This is a secondary analysis of a dataset from the PHTR from 2003-2019. We excluded encounters with a documented medical officer, medic, or unknown prehospital provider at any time in their chain of care during the Role 1 phase to isolate only casualties with BFR medical care. RESULTS: Of the 1,357 encounters in our initial dataset, we identified 29 casualties that met inclusion criteria. Pressure dressing was the most common intervention (n=12), followed by limb tourniquets (n=4), IV fluids (n=3), hemostatic gauze (n=2), and wound packing (n=2). Bag-valve-masks, chest seals, extremity splints, and nasopharyngeal airways (NPA) were also used (n=1 each). Notably absent were backboards, blizzard blankets, cervical collars, eye shields, pelvic splints, hypothermia kits, chest tubes, supraglottic airways (SGA), intraosseous (I/O) lines, and needle decompression (NDC). CONCLUSIONS: Despite limited training, BFRs employ vital medical skills in the prehospital setting. Our data show that BFRs largely perform medical interventions within the scope of their medical knowledge and training. Better datasets with efficacy and complication data are needed.