Page 85 - Journal of Special Operations Medicine - Fall 2015

Data were extracted by ISR, which provided the investigators Figure 1 Study population.
with the data encrypted and password protected. No personal
health information (PHI) was accessed, and there was no mas-
ter list with such information generated or maintained. Elec-
tronic data were stored on a password-protected computer,
and no hard data were collected or stored.

Subject Population
This investigation defines the specific physiologic variables on
arrival to the Role 2/Role 3 emergency departments from the
POI (POI transport group); or from Role 2/Role 3 hospital
facilities to another Role 3 (intratheater transport group) for
combat causalities in OEF between 1 January 2010 and 31
December 2010 with an ISS greater than 15. By definition,
all study patients survived transportation as the DoDTR only
contains patients who are admitted alive to a Role 3 facility.
The ISS is an analytical tool that assesses trauma in all body ar-
eas and derives a composite score from the three most severely
injured regions. An ISS greater than 15 represents a severely Notes: POI = Point of Injury; BD = Base Deficit; INR = International
injured patient. Subjects in this analysis included critically in- Normalized Ratio.
jured (ISS > 15) combat casualties transported in OEF whose
biochemical markers (emergency department arrival BD and Table 1 Critical Care Interventions
INR) were recorded in the DoDTR database. Subjects were Intervention No.
US and North Atlantic Treaty Organization (NATO) military
personnel and did not include children, civilians, detainees, or Ventilatory support/intubation 92
non-NATO military personnel. Patients who do not meet these Cricothyrotomy 13
criteria were not included.
Double-lumen endotracheal tube 1
Statistical Analysis Needle decompression/tube thoracostomy 29
This study provides an analysis of described variables of cau- Central venous access 3
salities in the two study groups: POI transport and intratheater Cardiopulmonary resuscitation 9
transport. Emergency department BD and INR for patients
were tested for significance between POI and intratheater Total critical care interventions 147
transports. Because the distribution for BD was skewed to the
right and INR was skewed to the left, the t-test assumption of n = 1), as well as prolonged flight time (e.g., 51 minutes, n =
normality was violated and a rank-sum test was performed to 1). Other interventions performed during transport included
compare POI parameters to intratheater parameters. placement of peripheral intravenous lines, intraosseous lines,
and tourniquets and initiation of supplemental oxygen. While
these procedures can be lifesaving, they were not considered
Results critical care interventions for the purposes of this analysis

There were 1198 transportation events among 626 total pa- (Table 2).
tients that were identified in the DoDTR for patients with an
ISS greater than 15 in OEF between 1 January 2010 and 31 Of the POI transports, 478 (75.4%) had available data on
December 2010. Patients had a mean age of 25.2 years (range BD in the emergency department, with a mean value of –5.4
18 to 51 years). Twelve casualties were from the US Air Force, mEq/L (SD 6.78). Of intratheater transports, 521 (92.4%) had
279 were from the US Army, 162 were from the US Marine available data on BD, with a mean value of 0.68 mEq/L (SD
Corps, 11 were from the US Navy, and 162 were from other 4.82), yielding a p value <.001 between POI and intratheater
NATO forces. One hundred twenty-eight patients had a single transports. Of POI transports, 214 (33.8%) had available data
transportation event (e.g., single transport from POI to Role on INR in the emergency department, with a mean value of
2/3 MTF), and the remaining 498 had more than one trans- 1.48 (SD 0.71). Of intratheater transports, 507 (89.9%) had
portation event (e.g., POI to Role 2, then Role 2 to Role 3). Of available data on INR data, with a mean value of 1.21 (SD
the 1198 total events, 634 (53%) were POI transports and 564 0.29), yielding a p value <.001 between POI and intratheater
(47%) were intratheater transports (Figure 1). transports.

Critical care procedures performed during transportation (n Discussion
= 147, 12.3%) included intubation (n = 92), cricothyrotomy
(n = 13), double-lumen endotracheal tube placement (n = 1), This investigation helps quantify the number of patients who
needle or tube thoracostomy (n = 29), central venous access may benefit from a critical care skill set. These data demon-
placement (n = 3), and cardiopulmonary resuscitation (n = 9) strate that a significant number of troops transported during
(Table 1). Critical clinical events during transport included OEF required critical care interventions and that they showed
airway emergencies (e.g., “extubated en route and vomited,” significant improvement in BD and INR after resuscitation.

Resuscitation During Critical Care Transportation in Afghanistan 73