Tactical Combat Casualty Care

Journal Article Abstracts

May 2013

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References Bier SA, Hermstad E, Trollman C, Holdt M: Army flight medic performance of paramedic level procedures: indicated vs performed. J Emerg Med 2013;44:962-969 Brown JB, Cohen MJ, Minei, et al: Goal-directed resuscitation in the prehospital setting: a propensity-adjusted analysis. J Trauma Acute Care Surg 2013;74:1207-1214 Byodon M, Lin J, Macki M, et al: The role of steroids in acute spinal cord injury. World Neurosurg 2013;Epub ahead of print Clumpner B, Polston R, Kragh J, et al: Single versus double routing of the band in the combat application tourniquet. JSOM 2013;13:34-41 Flint L: The surgical legacies of Hawkeye Pierce. J Am Coll Surg 2013;212:515-524 Fox N, Rajani R, Bokahri F, et al: Evaluation and management of penetrating lower extremity arterial trauma: an Eastern Association of the Surgery of Trauma practice management guidelines. J Trauma Acute Care 2012;73:S315-S320 Gegel B, Burgert J, Gasko J, et al: The effects of QuickClot Combat Gauze and movement on hemorrhage control in a porcine model. Mil Med 2012;177:1543-1547 Harr J, Moore E, Ghasabyan A, et al: Functional fibrinogen assay indicates that fibrinogen is critical in correcting abnormal clot strength following trauma. Shock 2013;39:45-49 Inaba K, Karamanos E, Lustenberger T, et al: Impact of fibrinogen levels on outcomes after acute injury in patients requiring a massive transfusion. J Am Coll Surg 2013; Epub ahead of print Inaba K, Branco B, Rhee P, et al: Long-term preclinical evaluation of the intracorporeal use of advanced local hemostatics in a damage-control swine model of grade IV liver injury. J Trauma Acute Care Surg 2013;74:538-545 Kasotakis G, Sideris A, Yang Y, et al: Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients: an analysis of the Glue Grant database. J Trauma Acute Care Surg 2013;74:1215-1222

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Kheirabadi B, Terrazas I, Hanson M, et al: In vivo assessment of the Combat Ready Clamp to control junctional hemorrhage in swine. J Trauma Acute Care Surg 2013;74:1260-1265 Kheirabadi B, Terrazas I, Williams J, et al: Negative-pressure wound therapy: a hemostatic adjunct for control of coagulopathic hemorrhage in large soft tissue wounds. J Trauma Acute Care Surg 2013;73:1188-1194 Kontos A, Kotwal RS, Elbin RJ, Lutz RH, Forsten RD, Benson PJ, Guskiewicz KM: Residual effects of combat-related mild traumatic brain injury. J Neuro 2013;30:1-7 Kragh J, Beebe D, O’Neill M: Performance improvement in emergency tourniquet use during the Baghdad surge. Am J Emerg Med 2013; Epub ahead of print Kunio N, Riha G, Watson K, et al: Chitosa- based advanced hemostatic dressing is associated with decreased blood loss in a swine uncontrolled hemorrhage model. Am J Surg 2013;205;505-510 Lee T, Van P, Spoerke N: The use of lyophilized plasma in a severe multi-injury pig model. Transfusion 2013;53:72S-79S Lipsky A, Ganor O, Abramovich A, et al: Walking between the drops: Israeli Defense Forces’ fluid resuscitation protocol. J Emerg Med 2013;44:790-795 Martin M: Editorial to accompany “A pilot study of the use of kaolin-impregnated gauze (Combat Gauze) for packing high-grade hepatic injuries in a hypothermic coagulopathic swine model (JSURGRES –D-12-01536R1) “. J Surg Res 2013;Epub ahead of print Martin M, Satterly S, Inaba K, Blair K: Needle Thoracostomy for tension pneumothorax. J Trauma Acute Care Surg 2013;74:949 Morrison J, Poon H, Rasmussen T, et al: Resuscitative thoracotomy following wartime injury. J Trauma Acute Care Surg 2013;74:825-829 Murray C, Brunstetter T, Beckius M, et al: Evaluation of hemostatic field dressing for bacteria, mycobacteria, or fungus contamination. Mil Med 2013;178:e394-e397 NAEMSP Position Paper: EMS spinal precautions and the use of the long backboard. Prehosp Emerg Care 2013;3:1-2

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Perel P, Roberts I, Ker K: Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Review, Issue 3, 2013. Pusateri A, Weiskopf R, Bebarta V, et al: Tranexamic acid and trauma: current status and knowledge gaps with recommended research priorities. Shock 2013; Epub ahead of print Sailliol A, Martinaoud C, Cap A, et al: The evolving role of lyophilized plasma in remote damage control resuscitation in the French Armed Forces Health Service. Transfusion 2013;53:65S-71S Satterly S, Nelson D, Zwintscher N, et al: Hemostasis in a non-compressible hemorrhage model: an end-user evaluation of hemostatic agents in a proximal arterial injury. J Surg 2012;70:206-211 Schöchl H, Schlimp C, Voelckel W: Potential value of pharmacological protocols in trauma. Curr Opin Anesthesiol 2013; Epub ahead of print Seamon M, Doane S, Gaughan J, et al: Prehospital interventions for penetrating trauma victims: a prospective comparison between Advanced Life Support and Basic Life Support. Injury 2013; Epub ahead of print Sena M, Douglas G, Gerlach T, et al: A pilot study of the use of kaolin - impregnated gauze (Combat Gauze) for packing high-grade hepatic injuries in a hypothermic coagulopathic swine model. J Surg Res 2013;Epub ahead of print Strandenes G, Cap A, Cacic D, et al: Blood far forward - a whole blood research and training program for austere environments. Transfusion 2031;53:124S-130S Wafaisade A, Lefering R, Maegele M, et al: Administration of fibrinogen concentrate in exsanguinating trauma patients is associated with improved survival at 6 hours but not at discharge. J Trauma Acute Surg Care 2013;74:387-395 Walsh R, Heiner J, Kang C, et al: Emergency physician evaluation of a novel surgical cricothyroidotomy tool in simulated combat and clinical environments. Mil Med 2013;178:29-33 Weppener J, Lang M, Sunday R, Debiasse N: Efficacy of tourniquets exposed to the Afghanistan combat environment stored in individual first aid kits versus on the exterior of plate carriers. Mil Med 2013;178:334-337 Wild G, Anderdson D, Lund P: Round Afghanistan with a fridge. Army Med Corps 2013;159:24-29

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Zentai C, Grottke O, Spahn D, Rossaint R: Nonsurgical techniques to control massive bleeding. Anesthesiology Clin 2013;31:41-53 Zielinski M, Smoot D, Stubbs J, et al: The development and feasibility of a remote damage control resuscitation prehospital plasma transfusion protocol for warfarin reversal for patients with traumatic brain injury. Transfusion 2013;53:59S-64S

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Abstracts

J Emerg Med 2013;44:962-969 ARMY FLIGHT MEDIC PERFORMANCE OF PARAMEDIC LEVEL PROCEDURES: INDICATED VS. PERFORMED Scott A. Bier, MD,* Erik Hermstad, MD,† Christopher Trollman, DO,‡ and Melinda Holt, PHD§ Background: There is great disparity in the education, experience, and staffing requirements for civilian and Army aeromedical transports (AMT). Objective: This study sought to determine if medical skills beyond the standard training for Army flight medics were indicated and being performed on Army AMT missions. As a secondary measure, the percentage of indicated interventions performed by basic Emergency Medical Technician (EMT-B) and paramedic (EMT-P) flight medics were compared. Methods: This was a retrospective review of Army AMT charts including patients transported by an EMT-B-staffed unit in Iraq and an EMT-P-staffed unit in Afghanistan from July 2008 to June 2009. Charts were reviewed independently by two Emergency Medicine board-certified Army flight surgeons. Results: Of 984 interventions found to be indicated on the 406 charts that met inclusion criteria, 36% were rated as EMT-P level. Seventeen percent were indicated but not performed. EMT-Bs failed to perform indicated procedures 35% of the time vs. 3% in the EMT-P group (p < 0.001). For paramedic-level procedures, EMTBs failed to make 76% of appropriate interventions, compared to <1% in the EMT-P group (p < 0.001). Conclusions: There seems to be a substantial number of procedures beyond the scope of standard Army flight medic training being required for Army AMT missions. It seems that when advance interventions are indicated, those trained to the EMT-P level perform them significantly more often than those trained to Army standard. Based on the findings of this study, the authors suggest the Army consider adopting the standards required for civilian AMT.

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J Trauma Acute Care Surg 2013;74:1207-1214 Goal-directed resuscitation in the prehospital setting: A propensity-adjusted analysis Joshua B. Brown, MD, Mitchell J. Cohen, MD, Joseph P. Minei, MD, Ronald V. Maier, MD, Michael A. West, MD, Timothy R. Billiar, MD, Andrew B. Peitzman, MD, Ernest E. Moore, MD, Joseph Cuschieri, MD, Jason L. Sperry, MD, MPH, and The Inflammation and the Host Response to Injury Investigators, Pittsburgh, Pennsylvania BACKGROUND: The scope of prehospital (PH) interventions has expanded recently - not always with clear benefit. PH crystalloid resuscitation has been challenged, particularly in penetrating trauma. Optimal PH crystalloid resuscitation strategies remain unclear in blunt trauma as does the influence of PH hypotension. The objective was to characterize outcomes for PH crystalloid volume in patients with and without PH hypotension. METHODS: Data were obtained from a multicenter prospective study of blunt injured adults transported from the scene with ISS 9 15. Subjects were divided into HIGH (9500 mL) and LOW (e500 mL) PH crystalloid groups. Propensity-adjusted regression determined the association of PH crystalloid group with mortality and acute coagulopathy (admission International Normalized Ratio, 91.5) in subjects with and without PH hypotension (systolic blood pressure [SBP], G90 mm Hg) after controlling for confounders. RESULTS: Of 1,216 subjects, 822 (68%) received HIGH PH crystalloid and 616 (51%) had PH hypotension. Initial base deficit and ISS were similar between HIGH and LOW crystalloid groups in subjects with and without PH hypotension. In subjects without PH hypotension, HIGH crystalloid was associated with an increase in the risk of mortality (hazard ratio, 2.5; 95% confidence interval [95% CI], 1.3Y4.9; p G 0.01) and acute coagulopathy (odds ratio [OR], 2.2; 95% CI, 1.01Y4.9; p = 0.04) but not in subjects with PH hypotension. HIGH crystalloid was associated with correction of PH hypotension on emergency department (ED) arrival (OR, 2.02; 95% CI, 1.06Y3.88; p = 0.03). The mean corrected SBP in the ED was 104 mm Hg. Each 1 mm Hg increase in ED SBP was associated with a 2% increase in survival in subjects with PH hypotension (OR, 1.02; 95% CI, 1.01Y1.03; p G 0.01). CONCLUSION: In severely injured blunt trauma patients, PH crystalloid more than 500 mL was associated with worse outcome in patients without PH hypotension but not with PH hypotension. HIGH crystalloid was associated with corrected PH hypotension. This suggests that PH resuscitation should be goal directed based on the presence or absence of PH hypotension. LEVEL OF EVIDENCE: Therapeutic study, level III.

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World Neurosurg. 2013 Feb 20 [Epub ahead of print] The Role of Steroids in Acute Spinal Cord Injury. Bydon M, Lin J, Macki M, Gokalsan ZL, Bydon A. INTRODUCTION: Acute spinal cord injury (ASCI) is a catastrophic event that can profoundly affect the trajectory of a patient's life. Debate continues over the pharmacologic management of ASCI, namely the widespread but controversial use of the steroid methylprednisolone (MP). Limitations in understanding of the pathobiology of ASCI and the difficulty in proving the efficacy of therapies combine to curtail treatment efforts. BODY: In this review, the authors discuss the pathophysiology of acute spinal cord injury as well as the laboratory and clinical findings on the use of methylprednisolone (MP). The use of MP remains a contentious issue, partly due to the catastrophic nature of ASCI, the paucity of treatment options, and the legal ramifications. While the historical data on the use of MP in ASCI have been challenged, recent studies have been used to both support and oppose treatment of ASCI with steroids. CONCLUSION: ASCI is a devastating event with a complex aftermath of secondary damaging processes that worsen the initial injury. Although the results of NASCIS II and III trials led to the widespread adoption of a high-dose MP regimen for patients treated within eight hours of injury, subsequent studies have called into question the validity of NASCIS conclusions. Further evidence of the ineffectiveness of the MP protocol has led to declining confidence in the treatment over the last decade. At present, it cannot be recommended as a standard of care, but it remains an option until supplanted by future evidence-based therapies.

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J Spec Oper Med. 2013 Spring;13(1):34-41. Single versus Double Routing of the Band in the Combat Application Tourniquet. Clumpner BR, Polston RW, Kragh JF Jr, Westmoreland T, Harcke HT, Jones JA, Dubick MA, Baer DG, Blackbourne LH. Background: Common first aid tourniquets, like the Combat Application Tourniquet (CAT) of a windlass and band design, can have the band routed through the buckle in three different ways, and recent evidence indicates users may be confused with complex doctrine. Objective: The purpose of the present study is to measure the differential performance of the three possible routings in order to better understand good tourniquet practice. Methods: A training manikin was used by two investigators to measure tourniquet effectiveness, time to stop bleeding, and blood loss. Results: The effectiveness rate was 99.6% (239/240) overall. Results were similar for both single-slit routings (inside vs. outside, p > 0.05). Effectiveness rates (yes-no results for hemorrhage control expressed as a proportion of iterations) were not statistically different between single and double routing. However, the time to stop bleeding and blood loss were statistically different (p < 0.05). Conclusions: CAT band routing, through the buckle either singly or doubly, affects two key performance criteria: time to stop bleeding and volume of blood lost. Single routing proved to be faster, thereby saving more blood. Learning curves required to optimize user performance varied over 30-fold depending on which variable was selected (e.g., effectiveness vs. blood loss).

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J Am Coll Surg. 2013 Apr;216(4):515-24 The surgical legacies of Hawkeye Pierce. Flint L. Excerpt:

“In my opinion, the most important advance in the care of combat injuries in the Iraq and Afghanistan wars has been the successful adoption, extension, and refinement by the military, of approaches and techniques that had been implemented and proven to be effective in civilian trauma systems. These system components include a tiered response structure, early control in the field of bleeding using tourniquets and hemostatic bandages, rapid evacuation to definitive care, hemostatic resuscitation, rapid operative hemostasis, external fracture fixation, and wound debridement. Initial operations are abbreviated using the principles of “damage control.” Patients are rapidly evacuated to facilities staffed with trained specialists using sophisticated air evacuation systems. At these facilities, sequential debridements and definitive reconstructions are continued. Follow-up information is provided using system-wide telemedicine conferences and patient data are entered and stored in a trauma registry. These data provide the foundations for multidisciplinary, multisite clinical research projects. Improved training of soldiers and medics to provide focused prehospital care interventions, such as the use of tourniquets to control bleeding from extremity injuries, has led to improved outcomes. Civilian consultants to the Civil War armies recommended the equipping of soldiers with tourniquets, but adoption of tourniquets for in-field use was delayed because of the belief that amputation occurred not because of the injury but because of tourniquet use. Trunkey, in his Churchill Lecture, emphasizes the value of modern tourniquets that can be applied with one hand. Data are available confirming improved survival with the application of tourniquets before the development of clinical signs of shock. Hemostatic bandages are used to accelerate local clotting and reduce blood loss. Several types of hemostatic bandage are available. These can be conventional gauze dressings treated with procoagulant chemicals, such as chitosan, or gauze bandages that incorporate fibers such as bamboo. Some hemostatic bandages can generate heat and cause tissue burning, but most have minimal adverse side effects. Recent data suggests these adjuncts can be useful to limit blood loss from soft-tissue injuries resulting from improvised explosive devices and during operative procedures.”

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J Trauma Acute Care Surg. 2012 Nov;73(5 Suppl 4):S315-20 Evaluation and management of penetrating lower extremity arterial trauma: an Eastern Association for the Surgery of Trauma practice management guideline. Fox N, Rajani RR, Bokhari F, Chiu WC, Kerwin A, Seamon MJ, Skarupa D, Frykberg E; Eastern Association for the Surgery of Trauma. BACKGROUND: Extremity arterial injury after penetrating trauma is common in military conflict or urban trauma centers. Most peripheral arterial injuries occur in the femoral and popliteal vessels of the lower extremity. The Eastern Association for the Surgery of Trauma first published practice management guidelines for the evaluation and treatment of penetrating lower extremity arterial trauma in 2002. Since that time, there have been advancements in the management of penetrating lower extremity arterial trauma. As a result, the Practice Management Guidelines Committee set out to develop updated guidelines. METHODS: A MEDLINE computer search was performed using PubMed (www.pubmed.gov). The search retrieved English language articles regarding penetrating lower extremity trauma from 1998 to 2011. References of these articles were also used to locate articles not identified through the MEDLINE search. Letters to the editor, case reports, book chapters, and review articles were excluded. The topics investigated were prehospital management, diagnostic evaluation, use of imaging technology, the role of temporary intravascular shunts, use of tourniquets, and the role of endovascular intervention. RESULTS: Forty-three articles were identified. From this group, 20 articles were selected to construct the guidelines. CONCLUSION: There have been changes in practice since the publication of the previous guidelines in 2002. Expedited triage of patients is possible with physical examination and/or the measurement of ankle-brachial indices. Computed tomographic angiography has become the diagnostic study of choice when imaging is required. Tourniquets and intravascular shunts have emerged as adjuncts in the treatment of penetrating lower extremity arterial trauma. The role of endovascular intervention warrants further investigation.

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Mil Med. 2012 Dec;177(12):1543-7. The effects of QuikClot Combat Gauze and movement on hemorrhage control in a porcine model. Gegel B, Burgert J, Gasko J, Campbell C, Martens M, Keck J, Reynolds H, Loughren M, Johnson D. Abstract: The purpose of this study was twofold: (1) to examine the effectiveness of QuikClot Combat Gauze (QCG) compared to a control group and (2) investigate the effect of movement on hemorrhage control when QCG is employed. This was a prospective, experimental design employing an established porcine model of uncontrolled hemorrhage. The minimum number of animals (n = 11 per group) was used to obtain a statistically valid result. There were no statistically significant differences between the groups (p > 0.05) indicating that the groups were equivalent on the following parameters: activating clotting time, the subject weights, core body temperatures, amount of 1 minute hemorrhage, arterial blood pressures, and the amount and percentage of total blood volume. There were significant differences in the amount of hemorrhage (p = 0.018) and the number of movements (p = 0.000) between the QCG and control. QCG is statistically and clinically superior at controlling hemorrhage compared to the standard pressure dressing control group. Furthermore, it produces a more robust clot that can with stand significant movement. In conclusion, QCG is an effective hemostatic agent for use in civilian and military trauma management.

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Shock. 2013 Jan;39(1):45-9. Functional fibrinogen assay indicates that fibrinogen is critical in correcting abnormal clot strength following trauma. Harr JN, Moore EE, Ghasabyan A, Chin TL, Sauaia A, Banerjee A, Silliman CC. Abstract: Thromboelastography (TEG) is emerging as the standard in the management of acute coagulopathies in injured patients. Although TEG is sensitive in detecting abnormalities in clot strength, one shortcoming is differentiating between fibrinogen and platelet contributions to clot integrity. Current American algorithms suggest platelet transfusion, whereas European guidelines suggest fibrinogen concentrates for correcting low clot strength. Therefore, we hypothesized that a TEG-based functional fibrinogen (FF) assay would assess the contribution of fibrinogen and platelets to clot strength and provide insight to transfusion priorities. Blood samples were obtained from trauma patients on arrival to the emergency department or who were admitted to the surgical intensive care unit (n = 68). Citrated kaolin TEG, FF, and von Clauss fibrinogen levels (plasma-based clinical standard) were measured. Correlations were assessed using linear regression models. In vitro studies were also performed with adding fibrinogen concentrates to blood collected from healthy volunteers (n = 10). Functional fibrinogen and citrated kaolin TEG parameters were measured. Functional fibrinogen strongly correlated with von Clauss fibrinogen levels (R = 0.87) and clot strength (R = 0.80). The mean fibrinogen contribution to clot strength was 30%; however, there was a direct linear relationship with fibrinogen level and percent fibrinogen contribution to clot strength (R = 0.83). Traditional TEG parameters associated with fibrinogen activity (α angle and kinetic time) had significantly lower correlations with FF (R = 0.70 and 0.35). Furthermore, platelet count had only a moderate correlation to clot strength (R = 0.51). The addition of fibrinogen concentrate in in vitro studies increased clot strength (MA) (60.44 ± 1.48 to 68.12 ± 1.39) and percent fibrinogen contribution to clot strength (23.8% ± 1.8% to 37.7% ± 2.5%). Functional fibrinogen can be performed rapidly with TEG and correlates well with the standard von Clauss fibrinogen assay. Both fibrinogen and platelet contribution of clot strength can be derived from FF. Moreover, FF had a stronger correlation to clot strength, and increased levels were directly associated with increased percent contribution to clot strength. In vitro studies also demonstrated an increase in FF, clot strength, and percent fibrinogen contribution to clot strength with the addition of fibrinogen concentrate. These data suggest that fibrinogen should be addressed early in trauma patients manifesting acute coagulopathy of trauma.

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J Am Coll Surg. 2013 Feb;216(2):290-7. Impact of fibrinogen levels on outcomes after acute injury in patients requiring a massive transfusion. Inaba K, Karamanos E, Lustenberger T, Schöchl H, Shulman I, Nelson J, Rhee P, Talving P, Lam L, Demetriades D. BACKGROUND: For critically injured patients requiring a massive transfusion, the optimal plasma fibrinogen level is unknown. The purpose of this study was to examine the impact of the fibrinogen level on mortality. We hypothesized that decreasing fibrinogen levels are associated with worse outcomes. STUDY DESIGN: All patients undergoing a massive transfusion from January 2000 through December 2011 were retrospectively identified. Those with a fibrinogen level measured on admission to the surgical ICU were analyzed according to their fibrinogen level (normal [≥180 mg/dL], abnormal [≥101 to <180 mg/dL], and critical [≤100 mg/dL]). Primary outcome was death. Multivariate analysis evaluated the impact of fibrinogen on survival. RESULTS: There were 260 patients who met inclusion criteria. Ninety-two patients had normal admission fibrinogen levels, 114 had abnormal levels, and 54 patients had critical levels. Patients with a critical fibrinogen level had significantly higher mortality at 24 hours compared with patients with abnormal (31.5% vs 5.3%; adj. p < 0.001) and normal fibrinogen levels (31.5% vs 4.3%; adjusted p < 0.001). Patients with a critical fibrinogen level had significantly higher in-hospital mortality compared with patients with abnormal (51.9% vs 25.4%; adjusted p = 0.013) and normal fibrinogen levels (51.9% vs 18.5%; adjusted p < 0.001). A critical fibrinogen level was the most important independent predictor of mortality (p = 0.012). CONCLUSIONS: For patients undergoing a massive transfusion after injury, as the fibrinogen level increased, a stepwise improvement in survival was noted. A fibrinogen level ≤100 mg/dL was a strong independent risk factor for death. The impact of an aggressive fibrinogen replacement strategy using readily available products warrants further prospective evaluation.

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J Trauma Acute Care Surg. 2013 Feb;74(2):538-45 Long-term preclinical evaluation of the intracorporeal use of advanced local hemostatics in a damage-control swine model of grade IV liver injury. Inaba K, Branco BC, Rhee P, Putty B, Okoye O, Barmparas G, Talving P, Demetriades D. BACKGROUND: The purpose of this study was to evaluate the long-term efficacy and safety of kaolin- and chitosan-based hemostatic agents for hemorrhage control in a 14-day survival, damage-control swine model of Grade IV liver injury. METHODS: A total of 48 anesthetized pigs (40 kg) underwent a 35% total blood volume bleed, cooling to 34°C and a standardized liver injury. The animals were randomized to standard gauze control (SG, n = 12), QuikClot Combat Gauze (QCCG, n = 12), Celox (CX, n = 12), or Celox Gauze (CXG, n = 12) packing. At 15 minutes, shed blood was calculated, followed by damage-control closure. At 48 hours, pack removal and definitive closure was performed. At 14-day acrifice, the liver, kidney, heart, lung, and small bowel standard intra-abdominal organs were sampled for histopathological examination. RESULTS: Uncontrolled blood loss at 2 minutes demonstrated internal consistency of the injury. Blood loss at 15 minutes was significantly lower in the CX and QCCG arms (SG, 11.1 ± 1.1 mL/kg; QCCG, 5.3 ± 1.2 mL/kg; CX, 5.7 ± 1.2 mL/kg; and CXG, 10.1 ± 1.3 mL/kg; p = 0.002). Forty-eight-hour survival was 50.0% for SG, 58.3% for QCCG, 83.3% for CX, and 41.7% for CXG (p = 0.161). Fourteen-day survival was 41.7% (5) for SG, 50.0% (6) for QCCG, 58.3% (7) for CX, and 41.7% (5) for CXG (p = 0.821). Four CX and two QCCG deaths were caused by bowel obstruction; one SG death was caused by sepsis; the remainder was caused by bloodloss. Histopathology in one CX animal demonstrated eosinophilic material within a coronary vessel consistent with granule embolization. CONCLUSION: Celox and QuikClot Combat Gauze were effective hemostatic adjuncts to standard intracavitary damage-control packing. The hemostasis was durable, facilitating pack removal, and definitive closure at reoperation. There was however an increase in the development of intra-abdominal adhesions resulting in small bowel obstruction. The potential for distant embolization of granular agents warrants further investigation.

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J Trauma Acute Care Surg. 2013 May;74(5):1215-22 Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients: An analysis of the Glue Grant database. Kasotakis G, Sideris A, Yang Y, de Moya M, Alam H, King DR, Tompkins R, Velmahos G; Inflammation and Host Response to Injury Investigators. BACKGROUND: Evidence suggests that aggressive crystalloid resuscitation is associated with significant morbidity in various clinical settings. We wanted to assess whether aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients. METHODS: Data were derived from the Glue Grant database. Our primary outcome measure was all-cause in-hospital mortality. Secondary outcomes included days on mechanical ventilation; intensive care unit (ICU) and hospital length of stay (LOS); inflammatory (acute lung injury and adult respiratory distress syndrome, or multiple-organ failure) and resuscitation-related morbidity (abdominal and extremity compartment syndromes or acute renal failure) and nosocomial infections (ventilator-associated pneumonia, bloodstream, urinary tract, and surgical site infections). RESULTS: In our sample of 1,754 patients, in-hospital mortality was not affected, but ventilator days (p < 0.001) as well as ICU (p = 0.009) and hospital (p = 0.002) LOS correlated strongly with the amount of crystalloids infused in the first 24 hours after injury. Amount of crystalloid resuscitation was also associated with the development of adult respiratory distress syndrome (p < 0.001), multiple-organ failure (p < 0.001), bloodstream (p = 0.001) and surgical site infections (p < 0.001), as well as abdominal (p < 0.001) and extremity compartment syndromes (p = 0.028) in a dose-dependent fashion, when age, Glasgow Coma Scale (GCS), severity of injury and acute physiologic derangement, comorbidities, as well as colloid and blood product transfusions were controlled for. CONCLUSION: Crystalloid resuscitation is associated with a substantial increase in morbidity, as well as ICU and hospital LOS in adult blunt trauma patients. LEVEL OF EVIDENCE: Therapeutic study, level III.

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J Trauma Acute Care Surg. 2012 Nov;73(5):1188-94 Negative-pressure wound therapy: a hemostatic adjunct for control of coagulopathic hemorrhage in large soft tissue wounds. Kheirabadi BS, Terrazas IB, Williams JF, Hanson MA, Dubick MA, Blackbourne LH. BACKGROUND: Negative-pressure wound therapy has been commonly used for treating chronic wounds and recently applied for treatment of traumatic wounds. We investigated the potential hemostatic benefit of negative-pressure wound therapy for control of refractory hemorrhage in a soft tissue wound model in swine. METHODS: Coagulopathy was induced in pigs (n = 38, 36 kg) by hemodilution and hypothermia. Next, a large soft tissue wound (diameter, approximately 20 cm) was created by slicing the gluteus maximus muscle. Free bleeding was allowed for 1 minute, and wounds were then randomly dressed with either laparotomy gauze (G) alone or TraumaPad (TP, a kaolin-coated dressing) alone or in combination with negative pressure (NP, approximately -500 mm Hg). All wounds were sealed with adhesive drapes. Fluid resuscitation was administered and targeted to mean arterial pressure of 60 mm Hg. Pigs were observed for 150 minutes or until death after which tissues were sampled for histologic examination. RESULTS: Induced coagulopathy as measured by increases in prothrombin time (12%) and activated partial thromboplastin time (22%) and decreases in fibrinogen (48%) were similar in all groups. There were no differences in initial bleeding rates (4.5 mL/kg/min). Dressing the wounds with G or TP produced hemostasis only in one pig (1 of 18 pigs). Addition of NP to these dressings secured hemostasis in 70% (G) and 90% (TP) of animals with average hemostasis time of 34 minutes and 25 minutes, respectively. Blood losses and fluid resuscitation requirements were significantly less, and survival times were significantly longer in NP adjunct groups than in the other groups. Survival rates were 80% (G+NP) and 90% (TP+NP) versus 0% (G) and 10% (TP) in the respective groups. Histologic examination showed similar superficial myofibril damages in all groups. CONCLUSION: To our knowledge, the present data provide the first evidence that NP serves as an effective hemostatic adjunct and when combined with standard hemostatic dressing, it is able to stop lethal coagulopathic bleeding in large soft tissue wounds.

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J Neurotrauma. 2013 Apr 15;30(8):680-6 Residual effects of combat-related mild traumatic brain injury. Kontos AP, Kotwal RS, Elbin RJ, Lutz RH, Forsten RD, Benson PJ, Guskiewicz KM. Abstract: Mild traumatic brain injury (mTBI) has gained considerable notoriety during the past decade of conflict in Afghanistan and Iraq. However, the relationship between combat-related mTBI and residual mTBI symptoms, post-traumatic stress disorder (PTSD) symptoms, and neurocognitive deficits remains unclear. The purpose of the study was to compare residual mTBI and PTSD symptoms, and neurocognitive deficits among U.S. Army Special Operations Command (USASOC) personnel with diagnosed blunt, blast, and blast-blunt combination mTBIs. This study involved a retrospective medical records review of 27,169 USASOC personnel who completed a military version of the Immediate Post-Concussion Assessment Cognitive Test (ImPACT), Post-Concussion Symptom Scale (PCSS), and PTSD Checklist (PCL) between November 2009 and December 2011. Of the 22,203 personnel who met criteria for the study, 2,813 (12.7%) had a diagnosis of at least one mTBI. A total of 28% (n=410) of USASOC personnel with a history of diagnosed mTBI reported clinical levels of PTSD symptoms. Personnel with a history of diagnosed blunt (OR=3.58), blast (OR=4.23) or combination (OR=5.73) mTBI were at significantly (p=0.001) greater risk of reporting clinical levels of PTSD symptoms than those with no history of mTBI. A dose-response gradient for exposure to blast/combination mTBI on clinical levels of PTSD symptoms was also significant (p=0.001). Individuals with blast/combination mTBIs scored higher in residual mTBI (p=0.001) and PTSD symptoms (p=0.001), and performed worse on tests of visual memory (p=0.001), and reaction time (p=0.001) than those with blunt or no mTBI history. Individuals with combination mTBIs scored lower in verbal memory (p=0.02) than those with blunt mTBIs. Residual PTSD and mTBI symptoms appear to be more prevalent in personnel with blast mTBI. A dose-response gradient for blast mTBI and symptoms suggests that repeated exposures to these injuries may have lingering effects.

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Am J Emerg Med. 2013 Mar 4. pii: S0735-6757(12)00611-0. doi: 10.1016/j.ajem.2012.11.030. [Epub ahead of print] Performance improvement in emergency tourniquet use during the Baghdad surge. Kragh JF Jr, Beebe DF, O'Neill ML, Beekley AC, Dubick MA, Baer DG, Blackbourne LH.

Excerpts: “The main finding of the current study is that the results indicate growing breadth, depth, and utility of emergency tourniquet use. For example, more frequent and earlier use of emergency tourniquets was associated with improved clinical performance. The work of serious quality improvement in tourniquet use was incremental, arduous, and sustained in what has been described as the most chaotic and stressful environment imaginable for doing science. The military services used tourniquets more often in later periods to try saving all lives possible by not missing anyone needing limb hemorrhage control. As we managed the military's emergency tourniquet program, we monitored the miss rate of US casualties with isolated limb exsanguination (including no tourniquet use and death), and the rate has been nearly zero for some time now. Lessons learned from the current study, if broadcast widely, may improve performance elsewhere.” “Another finding of the current study is that trends of tourniquet use earlier, more often, and more effectively in the care of casualties were associated with improved clinical performance and outcomes. The increased rate of tourniquets used per day and per casualty indicated a growing reliance on tourniquets for hemorrhage control on the current battlefield.”

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Am J Surg. 2013 May;205(5):505-10 Chitosan based advanced hemostatic dressing is associated with decreased blood loss in a swine uncontrolled hemorrhage model. Kunio NR, Riha GM, Watson KM, Differding JA, Schreiber MA, Watters JM. BACKGROUND: The purpose of this study was to compare standard gauze (SG) and advanced hemostatic dressings in use by military personnel in a no-hold model. METHODS: A randomized, controlled trial was conducted using 36 swine. Animals underwent femoral arteriotomy, followed by 60 seconds of uncontrolled hemorrhage. After hemorrhage, packing with 1 of 3 dressings -SG, Combat Gauze (CG), or Celox Rapid gauze (XG) - and a 500 mL bolus of Hextend were initiated. Pressure was not held after packing, and animals were followed for 120 minutes. Physiologic parameters were monitored continuously, and electrolyte and hematologic laboratory assessments were performed before injury and 30 and 120 minutes after injury. Dressing failure was determined if bleeding occurred outside the wound. RESULTS: All animals survived to study end. Baseline characteristics were similar between groups. No statistical difference was seen in initial blood loss or dressing success rate (SG, 10 of 12; CG, 10 of 12; and XG, 12 of 12). Secondary blood loss was significantly less with XG (median, 12.8 mL; interquartile range, 8.8 to 39.7 mL) compared with SG (median, 44.7 mL; interquartile range, 17.8 to 85.3 mL; P = .02) and CG (median, 31.9 mL; interquartile range, 18.6 to 69.1 mL; P = .05). Packing time was significantly shorter with XG (mean, 37.1 ± 6.2 seconds) compared with SG (mean, 45.2 ± 6.0 seconds; P < .01) and CG (mean, 43.5 ± 5.6 seconds; P = .01). CONCLUSIONS: XG demonstrated shorter application time and decreased secondary blood loss in comparison with both SG and CG. These differences may be of potential benefit in a care-under-fire scenario.

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Transfusion. 2013 Jan;53 Suppl 1:72S-79S The use of lyophilized plasma in a severe multi-injury pig model. Lee TH, Van PY, Spoerke NJ, Hamilton GJ, Cho SD, Watson K, Differding J, Schreiber MA. BACKGROUND: Shock and severe tissue injury lead to an endogenous coagulopathy mediated by activation of Protein C and hyperfibrinolysis known as acute traumatic coagulopathy. Together, hemodilution, acidosis, inflammation, and hypothermia result in a global trauma-induced coagulopathy. Coagulopathy in trauma is associated with mortality. Early and effective hemostatic resuscitation is critical in restoring perfusion, correcting coagulopathy, and saving lives in exsanguinating trauma. Lyophilized plasma (LP) provides a logistically superior alternative to fresh frozen plasma (FFP). STUDY DESIGN AND METHODS: Plasma was lyophilized following whole blood collection from anesthetized swine. A series of studies were performed using anesthetized swine subjected to a validated model of polytrauma and hemorrhagic shock including a Grade V liver injury. Animals were randomized to resuscitation using reconstituted LP fluids. Physiologic data and blood loss were measured. Coagulation status and inflammatory mediators were evaluated. RESULTS: Full volume reconstituted LP (100% LP) retains on average 86% coagulation factor activity compared to fresh plasma and when used in 1:1 ratios with red blood cells demonstrated superior hemostatic efficacy compared to FFP. Hypertonic LP reconstituted using 50% of the original plasma volume (50% LP) had higher coagulation factor concentrations, was well tolerated in swine, and equally effective compared to 100% LP with respect to physiologic and hemostatic properties. Buffering with ascorbic acid resulted in significant reductions in serum levels of tumor necrosis factor alpha and interleukin-6. CONCLUSION: By minimizing the volume of reconstituted LP and optimizing its anti-inflammatory properties, an LP resuscitation fluid may be created to provide effective hemostatic resuscitation with superior logistical properties.

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J Emerg Med. 2013 Apr;44(4):790-5 Walking between the drops: Israeli defense forces' fluid resuscitation protocol. Lipsky AM, Ganor O, Abramovich A, Katzenell U, Glassberg E. BACKGROUND: Current research in trauma resuscitation indicates that it is important to strike a balance between withholding intravenous fluid therapy, on one hand, and giving too much, on the other. The Israel Defense Forces' former protocol for prehospital fluid administration in the trauma setting was intended to navigate this balancing act. It turned out that the protocol was not being appropriately implemented in field conditions. OBJECTIVES: We describe our process improvement, which resulted in our revised protocol. Our goal in drafting the new protocol was to achieve yet another balance, this time between the recommendations derived from accumulating science, and the efficacy with which they could likely be implemented in the field. DISCUSSION: We review the available research in prehospital fluid administration, and then develop our current protocol. Per our a priori requirements, the protocol is unified in that medical personnel from a very wide spectrum of caregivers can apply it; and it is appropriate for both short evacuation time scenarios (e.g., low-intensity conflicts) and lengthier evacuation scenarios (e.g., high-intensity conflicts). CONCLUSION: Survival is likely improved if guidelines do not add unnecessary complexity and are easily implemented. We believe that the current protocol is suitable for the large majority of trauma patients, and helps guide providers toward a primary decision-point regarding fluid administration. Nonetheless, as long as only coarse clinical parameters for identifying shock are available, and data regarding optimal treatment are conflicting, offering truly balanced fluid resuscitation guidelines is a lot like walking between the drops. Excerpt: “….our protocol errs on the side of giving 500 mL to any casualty for whom there is a suspicion of shock (e.g., significant mechanism of injury), not just those with evidence of shock. Subsequent therapy, however, requires ongoing evidence of shock. Second, they chose Hextend over LR because it requires less volume to achieve a similar effect, thus reducing medic pack load. As our battlefront tends to be adjacent to our home front, we have fewer logistical transport and weight concerns, and the significant cost difference is not justifiable. Additionally, we feel that LR is likely more appropriate than Hextend for a wider spectrum of medical conditions, and LR, unlike Hextend, is not surrounded by unsettled debates concerning affects on coagulation.”

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J Surg Res. 2013 Mar 22 [Epub ahead of print] Editorial to accompany "A pilot study of the use of kaolin-impregnated gauze (Combat Gauze) for packing high-grade hepatic injuries in a hypothermic coagulopathic swine model (JSURGRES-D-12-01536R1)" Martin MJ. Excerpt: The promising results of this study point to the need for additional testing of CG and other advanced hemostatic dressings as an adjunct to intracavitary hemorrhage control. This work also highlights the importance of expanding the use of these products beyond the pre-hospital arena and into both the emergency department and operating room. Although familiarization with CG as part of the Tactical Combat Casualty Care course has become a requirement prior to deployment for combat medics and other first responders, there continues to be a glaring lack of familiarity or even basic understanding of these products among surgeons and other in-hospital personnel. Although they are relatively uncommon, I have encountered multiple situations of difficult intracavitary hemorrhage in the emergency department or operating room (in both civilian and military settings) that have responded to application of an advanced hemostatic dressing when other routine measures have failed. Familiarization with these products and their potential expanded applications should become part of the routine predeployment preparation of all hospital-based practitioners, particularly the surgeons who will be performing the major intracavitary procedures at forward-deployed facilities.

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J Trauma Acute Care Surg. 2013 Mar;74(3):949 Re: Needle thoracostomy for tension pneumothorax. Martin MJ, Satterly S, Inaba K, Blair K. Comment on J Trauma Acute Care Surg. 2012 Dec;73(6):1412-7. J Trauma Acute Care Surg. 2013 Mar;74(3):949. Excerpt: “…..we are now completing a trial using our porcine model and examining the use of a standard 5-mm laparoscopic trocar to decompress tension PTX. This study includes an analysis of safety by adding arms where the device is placed when no PTX is present and the lungs are fully expanded. Our preliminary data suggest that this approach is significantly more effective than standard NT, with no iatrogenic injuries to the heart or lungs when placed with no PTX present. It is surprising that we continue to use an intervention that has clearly been demonstrated to be suboptimal (NT) and have to resort to using devices that are designed for other applications rather than a device specifically designed for treatment of tension PTX. We applaud the ingenuity described by Dr Cotte and echo his call for an alternative to standard NT.”

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J Trauma Acute Care Surg. 2013 Mar;74(3):825-9 Resuscitative thoracotomy following wartime injury. Morrison JJ, Poon H, Rasmussen TE, Khan MA, Midwinter MJ, Blackbourne LH, Garner JP. BACKGROUND: The evidence for resuscitative thoracotomy (RT) in trauma patients following wartime injury is limited; its indications and timings are less defined in battle injury. The aim of this study was to analyze survival as well as the causes and times of death in patients undergoing RT within the context of modern battlefield resuscitation. METHODS: A retrospective cohort study was performed on consecutive admissions to a Field Hospital in Southern Afghanistan. All patients undergoing RT were identified using the UK Joint Theatre Trauma Registry. The primary outcome was 30-day mortality, and secondary outcomes included location of cardiac arrest, time from arrest to thoracotomy, and proportion achieving a return of spontaneous circulation. RESULTS: Between April 2006 to March 2011, 65 patients underwent RT with 14 survivors (21.5%). Ten patients (15.4%) had an arrest in the field with no survivors, 29 (44.6%) had an arrest en route with 3 survivors, and 26 (40.0%) had an arrest in the emergency department with 11 survivors. There was no difference in Injury Severity Scores (ISSs) between survivors and fatalities (27.3 [7.6] vs. 36.0 [22.1], p = 0.636). Survivors had a significantly shorter time to thoracotomy than did fatalities (6.15 [5.8] minutes vs. 17.7 [12.63] minutes, p < 0.01) CONCLUSION: RT following combat injury will yield survivors. Best outcomes are in patients who have an arrest in the emergency department or on admission to the hospital. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III.

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Mil Med 2013; 178:e394-e397 Evaluation of hemostatic field dressing for bacteria, mycobacteria, or fungus contamination. LTC(P) Clinton K. Murray, MC USA, CDR Tyson Brunstetter, MSC USN, Miriam Beckius, MPH, CAPT James Dunne, MC USN, Katrin Mende, PhD ABSTRACT: Infectious complications have a major impact on wounded warriors. Pathogens causing infections include multidrug-resistant bacteria, fungi, and mycobacteria. The potential sources for these pathogens include nosocomial transmission, the environment (e.g., dirt), or the patients (skin flora) themselves. The purpose of this pilot study was to explore the possibility that hemostatic field dressings might act as an inoculation source of pathogens into wounds. To accomplish this, hemostatic field dressings were assessed for the presence of bacterial, fungal, or mycobacterial contamination. We evaluated two samples of QuikClot Combat Gauze and two samples of CELOX Gauze subjected to normal stresses associated with storage after receipt from the manufacturer. We then evaluated 16 samples of QuikClot Combat Gauze that were collected from personnel deployed in Afghanistan and had undergone routine mechanical stress. Samples underwent screening with Trypticase Soy Broth, blood agar plates, MacConkey agar plates, CHROMagar Staphylococcus aureus plates, chocolate agar plates, Potato Flake agar, Lowenstein–Jensen media, and Middlebrook 7H11 media. No bacteria, fungi, or mycobacteria were recovered from the dressings. It does not appear that hemostatic field dressings are contaminated, even after subjected to field conditions. Further research is needed to identify inoculation sources of fungi and mycobacteria, which cause infections.

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Prehosp Emerg Care 2013;3:1-2 EMS SPINAL PRECAUTIONS AND THE USE OF THE LONG BACKBOARD National Association of EMS Physicians and American College of Surgeons Committee on Trauma ABSTRACT: This is the official position of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma regarding emergency medical services spinal precautions and the use of the long backboard. Excerpts: “Long backboards are commonly used to attempt to provide rigid spinal immobilization among emergency medical services (EMS) trauma patients. However, the benefit of long backboards is largely unproven.” “Appropriate patients to be immobilized with a backboard may include those with: - Blunt trauma and altered level of consciousness - Spinal pain or tenderness - Neurologic complaint (e.g., numbness or motor weakness) - Anatomic deformity of the spine - High-energy mechanism of injury and any of the following: Drug or alcohol intoxication Inability to communicate Distracting injury” “Patients for whom immobilization on a backboard is not necessary include those with all of the following: - Normal level of consciousness (Glasgow Coma Score [GCS] 15) - No spine tenderness or anatomic abnormality - No neurologic findings or complaints - No distracting injury - No intoxication” “Patients with penetrating trauma to the head, neck, or torso and no evidence of spinal injury should not be immobilized on a backboard.”

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Perel P, Roberts I, Ker K: Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Review, Issue 3, 2013. Colloids versus crystalloids for fluid resuscitation in critically ill patients (Review) Perel P, Roberts I, Ker K Background: Colloid solutions are widely used in fluid resuscitation of critically ill patients. There are several choices of colloid, and there is ongoing debate about the relative effectiveness of colloids compared to crystalloid fluids. Objectives: To assess the effects of colloids compared to crystalloids for fluid resuscitation in critically ill patients. Search methods: We searched the Cochrane Injuries Group Specialised Register (17 October 2012), the Cochrane Central Register of Controlled Trials (The Cochrane Library) (Issue 10, 2012), MEDLINE (Ovid) 1946 to October 2012, EMBASE (Ovid) 1980 to October 2012, ISI Web of Science: Science Citation Index Expanded (1970 to October 2012), ISI Web of Science: Conference Proceedings Citation Index-Science (1990 to October 2012), PubMed (October 2012), www.clinical trials.gov and www.controlled-trials.com. We also searched the bibliographies of relevant studies and review articles. Selection criteria: Randomised controlled trials (RCTs) of colloids compared to crystalloids, in patients requiring volume replacement. We excluded crossover trials and trials involving pregnant women and neonates. Data collection and analysis: Two review authors independently extracted data and rated quality of allocation concealment. We analysed trials with a ’double intervention’, such as those comparing colloid in hypertonic crystalloid to isotonic crystalloid, separately. We stratified the analysis according to colloid type and quality of allocation concealment. Main results: We identified 78 eligible trials; 70 of these presented mortality data. Colloids compared to crystalloids Albumin or plasma protein fraction - 24 trials reported data on mortality, including a total of 9920 patients. The pooled risk ratio (RR) from these trials was 1.01 (95% confidence interval (CI) 0.93 to 1.10). When we excluded the trial with poor-quality allocation concealment, pooled RR was 1.00 (95% CI 0.92 to 1.09).

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Hydroxyethyl starch - 25 trials compared hydroxyethyl starch with crystalloids and included 9147 patients. The pooled RR was 1.10 (95% CI 1.02 to 1.19). Modified gelatin - 11 trials compared modified gelatin with crystalloid and included 506 patients. The pooled RR was 0.91 (95% CI 0.49 to 1.72). (When the trials by Boldt et al were removed from the three preceding analyses, the results were unchanged.) Dextran - nine trials compared dextran with a crystalloid and included 834 patients. The pooled RR was 1.24 (95% CI 0.94 to 1.65). Colloids in hypertonic crystalloid compared to isotonic crystalloid - Nine trials compared dextran in hypertonic crystalloid with isotonic crystalloid, including 1985 randomised participants. Pooled RR for mortality was 0.91 (95% CI 0.71 to 1.06). Authors’ conclusions: There is no evidence from randomised controlled trials that resuscitation with colloids reduces the risk of death, compared to resuscitation with crystalloids, in patients with trauma, burns or following surgery. Furthermore, the use of hydroxyethyl starch might increase mortality. As colloids are not associated with an improvement in survival and are considerably more expensive than crystalloids, it is hard to see how their continued use in clinical practice can be justified.

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Shock. 2013 Feb;39(2):121-6 Tranexamic acid and trauma: current status and knowledge gaps with recommended research priorities. Pusateri AE, Weiskopf RB, Bebarta V, Butler F, Cestero RF, Chaudry IH, Deal V, Dorlac WC, Gerhardt RT, Given MB, Hansen DR, Hoots WK, Klein HG, Macdonald VW, Mattox KL, Michael RA, Mogford J, Montcalm-Smith EA, Niemeyer DM, Prusaczyk WK, Rappold JF, Rassmussen T, Rentas F, Ross J, Thompson C, Tucker LD; US DoD Hemorrhage and Resuscitation Research and Development Steering Committee. Abstract: A recent large civilian randomized controlled trial on the use of tranexamic acid (TXA) for trauma reported important survival benefits. Subsequently, successful use of TXA for combat casualties in Afghanistan was also reported. As a result of these promising studies, there has been growing interest in the use of TXA for trauma. Potential adverse effects of TXA have also been reported. A US Department of Defense committee conducted a review and assessment of knowledge gaps and research requirements regarding the use of TXA for the treatment of casualties that have experienced traumatic hemorrhage. We present identified knowledge gaps and associated research priorities. We believe that important knowledge gaps exist and that a targeted, prioritized research effort will contribute to the refinement of practice guidelines over time.

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Transfusion. 2013 Jan;53 Suppl 1:65S-71S The evolving role of lyophilized plasma in remote damage control resuscitation in the French Armed Forces Health Service. Sailliol A, Martinaud C, Cap AP, Civadier C, Clavier B, Deshayes AV, Mendes AC, Pouget T, Demazeau N, Chueca M, Martelet FR, Ausset S. Abstract: Freeze-dried plasma was developed by the US Army for the resuscitation of combat casualties during World War II. The French Military Blood Institute began producing French lyophilized plasma (FLYP) in 1949, in accordance with French blood product guidelines. Since 2010, a photochemical pathogen inactivation process has been implemented to reduce the remaining transfusion-related infectious risk. All quality controls for this procedure verify that the hemostatic properties of FLYP are conserved. FLYP is compatible with all blood types, can be stored at room temperature for 2 years, and its reconstitution requires less than 6 minutes. As a result, FLYP allows quick delivery of all the coagulation proteins and the application of a 1:1 ratio of FLYP and red blood cells in the context of a massive transfusion. Hemovigilance data collected in France since 1994 have included FLYP. Results indicate no reporting of infection related to the use of FLYP. Clinical monitoring with a focus on hemostasis was implemented in 2002 and expanded in 2010. The data, obtained from overseas operations, confirmed the indications, the safety and the clinical efficacy of FLYP. Further research is needed to determine specific indications for FLYP in the therapeutic management of civilian patients with severe hemorrhage.

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J Surg Educ. 2013 Mar-Apr;70(2):206-11 Hemostasis in a noncompressible hemorrhage model: an end-user evaluation of hemostatic agents in a proximal arterial injury. Satterly S, Nelson D, Zwintscher N, Oguntoye M, Causey W, Theis B, Huang R, Haque M, Martin M, Bickett G, Rush RM Jr. OBJECTIVE: 1. Evaluate hemostatic bandages by the end user using subjective and objective criteria. 2. Determine if user training and education level impact overall hemostatic outcomes. 3. Our hypothesis was that prior medical training would be directly linked to improved hemostatic outcomes in noncompressible hemorrhage independent of dressing used. DESIGN: Military personnel were given standardized instruction on hemostatic dressings as part of a tactical combat casualty care course (TC3). Soldiers were randomized to a hemostatic dressing. Proximal arterial (femoral and axillary) injuries were created in extremities of live tissue models (goat or pig). Participants attempted hemostasis through standardized dressing application. Evaluation of hemostasis was performed at 2- and 4-minute intervals by physicians blinded to participants' training level. SETTING: Military personnel that are due to deploy are given "refresher" instruction by their units as well as participating in the TC3 to further hone their medical skills prior to deployment. The TC3 is simulation training designed to simulate combat environments and real-life trauma scenarios. PARTICIPANTS: Military personnel due to deploy, physicians (residents and board certified surgeons), animal care technicians, and veterinarian support. RESULTS: Celox 42 (33%), ChitoGauze 11 (9%), Combat Gauze 45 (35%), and HemCon wafer 28 (22%) bandages were applied in 126 arterial injuries created in 45 animals in a standardized model of hemorrhage. Overall, no significant difference in hemostasis and volume of blood loss was seen between the 4 dressings at 2 or 4 minutes. Combat gauze was the most effective at controlling hemorrhage, achieving 83% hemostasis by 4 minutes. Combat gauze was also rated as the easiest dressing to use by the soldiers (p<0.05). When compared to nonmedical personnel, active duty soldiers with prior medical training improved hemostasis at 4 minutes by 20% (p = 0.05). CONCLUSIONS: There is no significant difference in hemostasis between hemostatic bandages for proximal arterial hemorrhage. Hemostasis significantly improves between 2 and 4 minutes using direct pressure and hemostatic agents. Prior medical training leads to 20% greater efficacy when using hemostatic dressings.

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Curr Opin Anaesthesiol. 2013 Apr;26(2):221-9 Potential value of pharmacological protocols in trauma. Schöchl H, Schlimp CJ, Voelckel W. PURPOSE OF REVIEW: Diagnosis and treatment of trauma-induced coagulopathy (TIC) presents a challenge for trauma care providers. Viscoelastic tests (VETs) including thromboelastometry and thrombelastography are increasingly used to diagnose TIC and guide hemostatic therapy. We summarize the concept of individualized, goal-directed coagulation management using coagulation factor concentrates. RECENT FINDINGS: Early and aggressive treatment is mandatory to improve the survival of severely bleeding trauma patients. High ratios of fresh frozen plasma to red blood cells are linked to improved outcome in coagulopathic patients; however, treatment is often delayed because most blood products must first be thawed. Lyophilized plasma potentially overcomes these problems. However, until now only limited data on the use of lyophilized plasma in major trauma are available. VETs provide a rapid and comprehensive overview of the coagulation process. Low maximum clot firmness is associated with increased transfusion requirements, and premature lysis of the clot is indicative of poor outcome. Improvement in clot firmness can be achieved by the administration of fibrinogen concentrate or platelet concentrate, depending on the cause of coagulopathy. Early administration of tranexamic acid improves clot stability and outcome in major trauma. Prothrombin complex concentrate increases thrombin generation, but is potentially associated with increased risk of thromboembolic complications. SUMMARY: VETs are useful in the diagnosis of TIC, allowing precise deficits in the coagulation process to be identified and specifically targeted with coagulation factor concentrates.

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Injury. 2013 May;44(5):634-8 Prehospital interventions for penetrating trauma victims: A prospective comparison between Advanced Life Support and Basic Life Support. Seamon MJ, Doane SM, Gaughan JP, Kulp H, D'Andrea AP, Pathak AS, Santora TA, Goldberg AJ, Wydro GC. BACKGROUND: Advanced Life Support (ALS) providers may perform more invasive prehospital procedures, while Basic Life Support (BLS) providers offer stabilization care and often "scoop and run". We hypothesized that prehospital interventions by urban ALS providers prolong prehospital time and decrease survival in penetrating trauma victims. STUDY DESIGN: We prospectively analyzed 236 consecutive ambulance-transported, penetrating trauma patients an our urban Level-1 trauma centre (6/2008-12/2009). Inclusion criteria included ICU admission, length of stay >/=2 days, or in-hospital death. Demographics, clinical characteristics, and outcomes were compared between ALS and BLS patients. Single and multiple variable logistic regression analysis determined predictors of hospital survival. RESULTS: Of 236 patients, 71% were transported by ALS and 29% by BLS. When ALS and BLS patients were compared, no differences in age, penetrating mechanism, scene GCS score, Injury Severity Score, or need for emergency surgery were detected (p>0.05). Patients transported by ALS units more often underwent prehospital interventions (97% vs. 17%; p<0.01), including endotracheal intubation, needle thoracostomy, cervical collar, IV placement, and crystalloid resuscitation. While ALS ambulance on-scene time was significantly longer than that of BLS (p<0.01), total prehospital time was not (p=0.98) despite these prehospital interventions (1.8±1.0 per ALS patient vs. 0.2±0.5 per BLS patient; p<0.01). Overall, 69.5% ALS patients and 88.4% of BLS patients (p<0.01) survived to hospital discharge. CONCLUSION: Prehospital resuscitative interventions by ALS units performed on penetrating trauma patients may lengthen on-scene time but do not significantly increase total prehospital time. Regardless, these interventions did not appear to benefit our rapidly transported, urban penetrating trauma patients. Excerpt: “Of the four prehospital procedures measured, cervical immobilisation and needle thoracostomy did not affect survival, while endotracheal intubation and attempted IV placement were associated with decreased survival.” * Note: The prehospital interventions listed did not include the use of tourniquets or hemostatic dressings.

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J Surg Res. 2013 Mar 13. pii: S0022-4804(13)00116-9. doi: 10.1016/j.jss.2013.02.039. [Epub ahead of print] A pilot study of the use of kaolin-impregnated gauze (Combat Gauze) for packing high-grade hepatic injuries in a hypothermic coagulopathic swine model. Sena MJ, Douglas G, Gerlach T, Grayson JK, Pichakron KO, Zierold D. BACKGROUND: Severe hepatic injuries may be highly lethal, and perihepatic packing remains the mainstay of treatment. This is not always successful, particularly in the setting of hypothermia and coagulopathy. Kaolin-impregnated Combat Gauze (CG) is an effective hemostatic dressing used primarily to treat external wounds. The objective of this study was to determine the ability of CG to control severe hemorrhage in hypothermic, coagulopathic swine with a high-grade hepatic injury. METHODS: Anesthetized animals underwent splenectomy and were cooled to 32°C while undergoing a 60% exchange transfusion with Hextend. A grade V liver injury was created in the left middle hepatic lobe. Animals were allowed to freely bleed for 30 s and then randomized to treatment with CG or plain gauze laparotomy pads (PG) applied to the injury site. Animals were then resuscitated with warmed Hextend. RESULTS: There was no difference between groups in preinjury hemodynamic or laboratory values. Animals packed with CG had less blood loss when compared with standard packing (CG = 25 mL/kg versus PG = 58 mL/kg, P = 0.05). There was a trend towards lower hetastarch resuscitation requirements in the CG group (CG = 7 mL/kg versus PG = 44 mL/kg, P = 0.06) but no statistically significant difference in mortality (CG = 13% versus PG = 50%, P = 0.11). Histology of the injury sites revealed more adherent clot in the CG group, but no inflammation, tissue necrosis, or residual material. CONCLUSION: In pigs with severe hepatic injury, Combat Gauze reduced blood loss and resuscitation requirements when compared with plain laparotomy pads. Combat Gauze may be safe and effective for use on severe liver injuries.

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Transfusion. 2013 Jan;53 Suppl 1:124S-130S. doi: 10.1111/trf.12046. Blood Far Forward--a whole blood research and training program for austere environments. Strandenes G, Cap AP, Cacic D, Lunde TH, Eliassen HS, Hervig T, Spinella PC. Abstract: The Blood Far Forward (BFF) research program was established to conduct blood product efficacy and safety studies, donor performance studies, and research on optimal training methods to improve the safety of blood collection and transfusion performed by Norwegian Naval Special Operation Commando soldiers. The use of intravenous fluids for volume replacement during hemorrhagic shock is controversial, but it is currently the standard of care. In the far-forward environment, large volume resuscitation for massive bleeding is a great challenge. Crystalloid and colloid solutions add weight and bulk to the medic's kit, require temperature sensitive storage, and should be warmed before infusion to prevent hypothermia. Excessive use of these solutions causes a dilutional coagulopathy, acidosis, and potentially increased inflammatory injury compared with blood products. Type-specific whole blood from an uninjured combat companion on the other hand is almost always available. It is warm, replaces intravascular volume, and provides oxygen delivery and hemostatic capacity to prevent or treat shock and coagulopathy. Whole blood may be ideal for the resuscitation of combat casualties with hemorrhagic shock. BFF program pilot studies on use of platelet-sparing leukoreduction filters, whole blood transport tolerance, donor performance, and autologous reinfusion of 24-hour ambient temperature stored whole blood have been performed and suggest the feasibility of expanding whole blood use in resuscitation. If successful, the BFF program will change tactics, techniques, and procedures with a new lifesaving capability.

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J Trauma Acute Care Surg. 2013 Feb;74(2):387-3; discussion 393-5 Administration of fibrinogen concentrate in exsanguinating trauma patients is associated with improved survival at 6 hours but not at discharge. Wafaisade A, Lefering R, Maegele M, Brockamp T, Mutschler M, Lendemans S, Banerjee M, Bouillon B, Probst C; Trauma Registry of DGU. BACKGROUND: Despite poor evidence and high costs, fibrinogen concentrate (FC) represents one of the most frequently used hemostatic agents in exsanguinating trauma. The aim was to assess whether the administration of FC in severely injured patients was associated with improved outcomes. METHODS: Patients documented in the Trauma Registry of the German Society for Trauma Surgery (primary admissions, Injury Severity Score [ISS] ≥16) who had received FC during initial care between emergency department (ED) arrival and intensive care unit admission (FC+) were matched with patients who had not received FC (FC-). RESULTS: The matched-pairs analysis yielded two comparable cohorts (n = 294 in each group) with a mean ISS of 37.6 ± 13.7 (FC+) and 37.1 ± 13.3 (FC-) (p = 0.73); the mean age was 40 ± 17 versus 40 ± 16 (p = 0.72), respectively. Patients were predominantly male (71.1% in both groups, p = 1.0). On emergency department arrival, hypotension (systolic blood pressure, ≤90 mm Hg) occurred in 51.4% (FC+) and 48.0% (FC-) (p = 0.41), and base excess was -7.4 ± 5.3 mmol/L for FC+ and was -7.5 ± 6.2 mmol/L for FC- (p = 0.96). Patients were administered 12.8 ± 14.3 (FC+) versus 11.3 ± 10.0 (FC-) packed red blood cell units (p = 0.20). Thromboembolism occurred in 6.8% (FC+) versus 3.4% (FC-) (p = 0.06), and multiple organ failure occurred in 61.2% versus 49.0% (p = 0.003), respectively. Whereas 6-hour mortality was 10.5% for FC+ versus 16.7% for FC- (p = 0.03), the mean time to death was 7.5 ± 14.6 days versus 4.7 ± 8.6 days (p = 0.006). The overall hospital mortality rate was 28.6% versus 25.5% (p = 0.40), respectively. CONCLUSION: This is the first study to investigate the effect of FC administration in bleeding trauma. In our large population of severely injured patients, the early use of FC was associated with a significantly lower 6-hour mortality and an increased time to death, but also an increased rate of multiple organ failure. A reduction of overall hospital mortality was not observed in patients receiving FC. LEVEL OF EVIDENCE: Therapeutic study, level IV.

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Mil Med. 2013 Jan;178(1):29-33. Emergency physician evaluation of a novel surgical cricothyroidotomy tool in simulated combat and clinical environments. Walsh R, Heiner J, Kang C, Hile D, Deering S. Abstract: We sought to investigate the performance of a novel cricothyroidotomy CRIC device compared to the traditional surgical in both simulated combat environments and the emergency department (ED) setting. Twenty U.S. Army staff and resident emergency medicine physicians were randomized to device and simulated setting order and performed cricothyroidotomies in the standard manner and with the CRIC device via the TraumaMan surgical simulator in three simulated settings: the ED, a day combat environment, and a night combat environment. Differences in procedural completion for the two methods in different settings were compared by two-tailed paired t-tests. The occurrence of major and minor procedural complications and questions presented as 5-point Likert scales to describe participants' preferences of cricothyroidotomy methods were compared by chi2 analysis. Time to incision, time to procedural completion, and rate of major and minor complications were not significantly different between the standard surgical method and the CRIC device (p > 0.05). In the simulated ED setting, 60% of participants preferred the standard surgical method (95% confidence interval: 38.5-81.5), whereas in the simulated combat settings, 50% of participants preferred each device (95% confidence interval: 28.1-71.9). In our population, we observed similar operator performance characteristics and physician preferences between the 2 methods in all simulated cricothyroidotomy settings.

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Mil Med 2013;178:334-337 Efficacy of tourniquets exposed to the Afghanistan combat environment stored in individual first aid kits versus on the exterior of plate carriers. LT Justin Weppner, MC USN; HM2 Michael Lang, USN; HM3 Robert Sunday, FMF USN; HM3 Nicholas Debiasse, FMF USN ABSTRACT: Between February and May 2010, 1st Battalion, 6th Marines reported a 10% (10/92) breakage rate for tourniquets. One theory suggested was that tourniquets were weakened by exposure to the Afghan environment. Our study was designed to compare three groups of Afghanistan-exposed tourniquets to unexposed tourniquets. The three experimental arms were: (1) Afghan-exposed tourniquets worn on the plate carrier, (2) Afghan-exposed tourniquets carried in the Individual First Aid Kit (IFAK) and wrapped in manufacturer plastic wrapping, and (3) Afghan-exposed tourniquets carried in the IFAK with the manufacturer plastic wrapping removed. The outcome measures of this study were efficacy, breakage, and number of turns required to successfully stop the distal pulse. Tourniquets worn on the plate carrier had an efficacy of 57%, which was significantly lower than the control efficacy rate of 95.2%. When compared to the control arm, there were no significant differences in efficacy between the tourniquets stored in the IFAK with or without manufacturing packaging. No control tourniquets or tourniquets stored in IFAKs broke; however, 46 (12%) of the plate carrier-exposed tourniquets did break. No statistically significant differences were found between the four groups with regard to the median number of turns required to stop the distal pulse.

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J R Army Med Corps 2013;159:24-29 Round Afghanistan with a fridge. Gareth Wild, D Anderson, P Lund ABSTRACT: Introduction This paper covers the contemporary deployment of blood products in the pre–hospital environment during extended field operations in Afghanistan. The equipment used was standard–issue to the British Armed Forces but used in a novel manner. The aim of this paper was to establish the reliability of the RCB42P blood bank and the concept of blood storage in the field during protracted vehicle-borne patrols. Method: TempIT tag data was collected for five patrols and analysed. Ambient temperatures varied immensely from minus 5°C to plus 50°C. Mitigation measures were introduced to reduce the exposure of the blood bank to radiated and ambient heat. Results: The blood bank is affected by radiated heat from the engine compartment on long journeys coupled with high ambient temperatures. However, this can be minimized by simple mitigation measures using insulation and passive cooling . Conclusions: The RCB42P blood bank is a robust unit capable of enduring a considerable amount of physical abuse and extremes of temperature. It is suitable for the storage of blood products on protracted vehicle-borne patrols in high ambient temperatures if the mitigation measures outlined are employed.

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Anesthesiol Clin. 2013 Mar;31(1):41-53 Nonsurgical techniques to control massive bleeding. Zentai C, Grottke O, Spahn DR, Rossaint R. Abstract: Significant advancements in nonsurgical and surgical approaches to control bleeding in severely injured patients have also improved the treatment of critical trauma-related coagulopathy. Nonsurgical procedures such as angiographic embolization are progressively considered to terminate arterial bleeding from pelvic fractures. The disturbance of coagulation may aggravate bleeding and hamper surgical procedures. The administration of coagulation factors and factor concentrates may be useful for correcting systemic coagulopathy and reducing the need for fresh frozen plasma, platelet, and red blood cell transfusions, which are associated with various adverse outcomes. In this review, nonsurgical management of critical trauma bleeding is discussed. Excerpt: “Overall, treatment with tranexamic acid decreased the rate of mortality and the risk of death as a result of hemorrhage. In addition, it was shown that early tranexamic acid treatment (within 1 hour) reduced the rate of death as a result of bleeding compared with its late application (1–3 hours). A nested control study also showed that patients with traumatic brain injury showed a decrease in the mean intracranial size of hemorrhage. Overall, treatment with tranexamic acid did not result in major adverse or thrombotic complications. Even before the results of these studies were published, the European guidelines for the management of bleeding recommended considering the use of tranexamic acid in bleeding trauma patients.68 Based on the findings of the CRASH-2 trial, it is likely that the early administration of antifibrinolytic treatment using tranexamic acid will be recommended as a first-line treatment of established or suspected hyperfibrinolysis in patients presenting with major blood loss after trauma.”

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Transfusion. 2013 Jan;53 Suppl 1:59S-64S. doi: 10.1111/trf.12037. The development and feasibility of a remote damage control resuscitation prehospital plasma transfusion protocol for warfarin reversal for patients with traumatic brain injury. Zielinski MD, Smoot DL, Stubbs JR, Jenkins DH, Park MS, Zietlow SP. BACKGROUND: The rapid reversal of warfarin in the setting of traumatic brain injury (TBI) has been associated with improved outcomes. Until now, remote reversal of hypocoagulable states has not been possible in the prehospital environment. This manuscript describes the development and analysis of a prehospital plasma transfusion protocol to reverse warfarin at the earliest possible moment after TBI. STUDY DESIGN AND METHODS: A retrospective review of all TBI patients receiving plasma transfusion(s) in the prehospital environment for warfarin reversal between February 2009 and September 2010 was conducted. Thawed plasma was carried on every air ambulance flight centered at the main campus. RESULTS: A total of 2836 flights carried over 2500 units of thawed plasma throughout the study period. During this time, 16 patients received prehospital plasma resuscitation, five of who were on warfarin with a concurrent TBI. The median Injury Severity Score was 17 (8.5-27.5) with a median Glasgow Coma Score of 13 (8-15) and a mortality rate of 40%. A median of 2 (1.5-2.0) units of thawed plasma and 0 (0-0) units of RBCs were transfused en route. The pretransfusion point-of-care international normalized ratio improved from 3.1 (2.3-4.0) to 1.9 (1.3-3.6) upon trauma center admission (serum sample). One hundred percent of the transported, but unused, thawed plasma underwent subsequent transfusion prior to expiration. CONCLUSIONS: Remote prehospital plasma transfusions effectively reverse anticoagulation secondary to warfarin administration in TBI patients. It is feasible to transfuse thawed plasma in the prehospital setting via remote damage control techniques without increasing waste. Prospective studies are needed to determine if this practice can improve outcomes in this population.