Page 58 - Journal of Special Operations Medicine - Fall 2017

combat injuries in Afghanistan, which assessed the effects of casualty response system and TCCC). Central Command
TXA administration at a fixed facility on mortality, throm- and its Joint Theater Trauma System capture all prehospital
boembolic complications, and total blood product use. The trauma care provided on the ground by all services in the Af-
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absolute reduction in overall inhospital mortality for the TXA ghanistan Theater. TCCC cards, DoD 1380 forms, and TCCC
group was 6.5%. Among the subgroup of patients requiring after-action reports provide the registry data.
massive blood transfusion (i.e., 10 or more units of packed
red blood cells in 24 hours), the absolute reduction in hospi- DoDTR Description
tal mortality was 13.7% (a relative reduction of 49%). In The DoDTR, formerly known as the Joint Theater Trauma
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contrast to CRASH-2, the MATTERs study found a statisti- Registry, is the data repository for DoD trauma-related inju-
cally significant increase in pulmonary emboli and deep vein ries. The DoDTR documents information about demographics,
thromboses in the TXA group. However, the TXA group in injury-producing incidents, diagnosis, treatment, and outcomes
this study had a higher injury burden (based on Injury Severity of injuries sustained by military and civilian personnel (U.S.
Score [ISS]) than the non-TXA group, which itself is associ- and non-U.S.) in wartime and peacetime from the point of in-
ated with thromboembolic complications. Interestingly, the jury to final disposition. JTS personnel linked patients to the
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number needed to treat (NNT) for CRASH-2 was 67 ; how- DoDTR for outcome data, when available.
7
ever, the data in the MATTERs study indicated an NNT of
approximately 7. 8 Data Set Development
We collected data on vital signs, level of medical provider
Prehospital data on the military use of TXA is very limited training, painful procedures, medications administered, evacu-
at this time. A retrospective review was conducted of both ation status, mental status, mechanism of injury, and battle
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Israeli emergency medical services and military TXA use (N = injury versus nonbattle injury status. We used the first set of
103). The military treated 62 patients to assess a protocol for recorded vital signs when multiple sets were available. To de-
22
point-of-injury TXA administration. 20,22 The Israeli studies in- termine the medical provider, we recorded the “highest level”
dicated similar experiences with TXA in both the military and provider documented in the following order: medical officer,
civilian settings, with both demonstrating feasibility of prehos- medic, nonmedic first responder. We placed all Afghan forces
pital administration. 20,22 The Spanish military published a case into a single category for this analysis; these included mili-
series from Afghanistan, but this was limited to 10 patients. 23 tary, and federal and local police. We performed the analysis
based on the assumption that rendered care was documented
Based on published literature, the Committee on TCCC added accordingly.
TXA to its guidelines in 2011. Per TCCC algorithm, TXA
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should be administered to patients “[i]f a casualty is antici- Patient Identification
pated to need significant blood transfusion (presents with Using the PHTR data, we searched for all patients who met
hemorrhagic shock, one or more major amputations, penetrat- one or more criteria for prehospital TXA administration based
ing torso trauma, or evidence of severe bleeding).” 24 on TCCC guidelines: hypotension, amputation, or penetrating
trauma to the torso. We then divided patients meeting one of
To the best of our knowledge, this study is the first to describe those inclusion criteria into two groups: those with and those
the proportions of eligible patients receiving prehospital TXA without documented prehospital TXA administration. We only
in accordance with TCCC guidelines. included gunshot wounds if they were documented to the torso.

Methods Data Analysis
We performed all statistical analyses using Microsoft Excel
Patients were casualties in Afghanistan during Operation En- (version 10; www.microsoft.com) and SPSS (version 24; IBM,
during Freedom from January 2013 to September 2014. We https://www.ibm.com). We compared study variables between
obtained prehospital data from the Prehospital Trauma Reg- patients receiving TXA using a Student t test for continuous
istry (PHTR), which is a module of the Department of De- variables, the Wilcoxon rank-sum test for ordinal variables,
fense Trauma Registry (DoDTR). The Joint Trauma System and χ test for nominal variables.
2
(JTS) compiles and maintains both databases at the U.S. Army
Institute of Surgical Research (USAISR). JTS personnel then Results
linked patients from the PHTR to the DoDTR to obtain fixed-
facility treatment and outcome data, when available. Because From January 2013 through September 2014, there were 737
only deidentified data were available to the research team, the encounters captured in the PHTR. Of the 737, 24 casualties
USAISR regulatory office determined that the study did not were killed in action, five were dead on arrival, and three were
require institutional review board review. enemy prisoners of war, all of whom were excluded from the
research database. Of the remaining 705 patients, 272 met in-
PHTR Description clusion criteria per TXA guidelines. Of these 272, 51 (18.8%)
The JTS PHTR is a data collection and analytic system de- received TXA and the remaining 221 (81.2%) did not. Table 1
signed to provide near real-time feedback to commanders. outlines the subgroup analyses for administration rates. Most
The primary purpose of this system is to improve casualty events (97.8%; n = 266) were battle injuries. One dose (2.0%)
visibility, and augment command decision-making processes of TXA was administered intraosseously; the rest were given
and direction of medical assets. Additionally, this system seeks intravenously (IV).
to improve morbidity and mortality through performance
improvement in the areas of primary prevention (i.e., tac- There were several differences in proportions of patients un-
tics, techniques, and procedures), secondary prevention (i.e., dergoing concomitant procedures in the TXA versus no-TXA
personal protective equipment), and tertiary prevention (i.e., groups (Table 2). Higher proportions of patients receiving

56 | JSOM Volume 17, Edition 3/Fall 2017