Page 86 - Journal of Special Operations Medicine - Fall 2015

Table 2 Resuscitation Markers
No. of Transports BD Data Available Mean BD INR Data Available Mean INR
Point of injury 634 478 (75.4%) –5.4 mEq/L 214 (33.8%) 1.48
Intratheater 564 521 (92.4%) 0.68 mEq/L 507 (89.9%) 1.21
Note: BD, base deficit; INR, international normalized ratio.

A detailed evaluation of transportation for combat wounded extends transportation times, aggressive resuscitation initiated
personnel can define the platform most appropriate for criti- as soon as possible offers the advantage of delivering a well-
cally injured patients requiring prolonged transit times. resuscitated patient to the doors of the trauma center.

Procedural Fluency Limitations
Those transportation events requiring some sort of critical care The decreased availability of prehospital data was a signifi-
procedural intervention totaled 147 (12.3% of transports) in cant limitation of this investigation. Specifically, only 33.8%
this subset of patients transported with an ISS greater than 15. of patients transported from POI had INR information avail-
While hemorrhage is the leading cause of survivable mortality able in the database. The lack of information in this subset of
on the battlefield, the thin margins for improvement in care patients makes interpretation of that element of the data set
can be found in improved airway management, management challenging. In general, there was a lack of POI information:
of thoracic trauma, and management of TBI. As Davis et al. BD (75.4% complete records) and INR (33.8% complete re-
noted, the improvement in outcome with critical care trans- cords). This underscores the need for more thorough attention
portation may be due to the ability to intubate and place chest to this important area of prehospital medical care outcomes
tubes. Oxygenation of “tissue at risk” is critical in the early research. Continued emphasis on accurate documentation in
10
management of trauma. Indeed, even a single episode of hypo- the DoDTR and in the medical record, such as has occurred
tension or hypoxemia can have profound effects on survival in with the ongoing “JTTS Tacevac Project” in Afghanistan, will
brain injury. Immediate availability of airway and ventilatory hopefully address this information data shortfall.
management can mitigate secondary brain injury in TBI, and
placement of chest tube drainage offers more definitive treat- The intratheater transport data included some Role 2 to Role
ment of thoracic injury than needle decompression. 3 MTF interfacility transports, representing another important
limitation of this analysis. Some of these interfacility trans-
Resuscitation ports were with Air Force Critical Care Air Transport Teams
BD/excess is the amount of base or acid required to bring 1 L (CCATT) (i.e., intensivist led), whereas some were by Army
of blood at body temperature (37°C) with a Paco of 40mmHg DUSTOFF Medics alone (Emergency Medical Technician led)
2
to pH 7.4. This laboratory assessment evaluates the metabolic and others were with Army DUSTOFF Medics augmented by
contribution to acid-base status and is an effective means to Army Flight Nurses. In addition, POI transports were under-
assess the adequacy of resuscitation. POI transports had a taken with a variety of transportation platforms, including US
remarkably lower rate of complete records for BD (75.4%) Army DUSTOFF, US Air Force Pedro (paramedic led), and UK
than intratheater transports (92.4%), and the BD was more MERT (intensivist led). Unfortunately, which platform was
abnormal in the POI transport group. The INR is a ratio of used on which transport is not defined in the DoDTR.
the sampled prothrombin time to a standardized prothrom-
bin time and serves as a measure of extrinsic coagulation. POI Finally, 128 patients had a single transportation event (POI
transports again had a low rate (33.8%) of complete records to Role 2 or 3), and the remaining 498 patients had multiple
for INR and had a mean value of 1.48, suggesting the pres- transportation events (POI to Role 2, then Role 2 to Role 3).
ence of coagulopathy. The POI transfer data describe a seri- The resuscitation that patients received between transporta-
ously injured cohort that are both acidotic and coagulopathic, tion events would obviously have the potential to affect the
a common finding in combat casualties and indicative of a variables discussed in this investigation. This may, however,
potentially high risk of mortality. simply draw attention to the improvement in resuscitation that
can be achieved by initiating resuscitation as early as possible.
These data suggest that early resuscitation is appropriate and
adequate; as demonstrated by the significant improvement Conclusions
in BD and INR. This is arguably supportive evidence for the
early damage control resuscitation strategy. To determine the Damage control resuscitation can be initiated during transport
ideal resuscitation window, it would be beneficial to look by “bringing the trauma bay to the patient,” thereby extending
more closely at the injury patterns, physiology, and surgical the reach of medical response teams. The international civil-
procedures carried out at these facilities. ian literature has demonstrated improved survival in severely
injured patients with critical care transportation, and recent
The alternative explanation that these values may simply re- military investigations have noted improved survival for sicker
flect shorter duration flights due to the current “load and go” patients with on-board intensive care.
philosophy cannot be excluded. Nevertheless, the concept
of “bringing the trauma bay to the patient” merits consider- In this investigation, critical care interventions were performed
ation. As the tyranny of distance in future conflicts potentially in 12.3% of transports. Our data show that combat casualties

74 Journal of Special Operations Medicine Volume 15, Edition 3/Fall 2015