Page 72 - JSOM Winter 2017

Table 1 Documented Team Resuscitation Interventions Table 2 Documented Team Surgical Interventions (N = 173 human
(N = 173 human casualties) casualties; n = 63 damage control surgeries)
Intervention No. (%) a Intervention No./Total (%)
Any intravenous access 88 (50.9) Any surgical intervention 63/173 (36.4)
Central venous access 15 (8.7) Cranial decompression 1/63 (1.6)
Intraosseous access 2 (1.2) Extremity amputation 1/63 (1.6)
Any airway intervention 51 (29.5) Thoracotomy 3/63 (4.8)
Endotracheal intubation 50 (28.9) Pericardial window 2/63 (3.2)
Cricothyrotomy 1 (0.6) Exploratory or damage control laparotomy 15/63 (23.8)
Thoracostomy tube 16 (9.2) Splenectomy 1/63 (1.6)
Splinting 12 (6.9) Renal repair or resection 1/63 (1.6)
Whole-blood administration 6 (3.5) Bladder repair or percutaneous drainage 1/63 (1.6)
Mean whole blood units, No. 3.3 Pancreatic drainage, resection, or repair 1/63 (1.6)
Packed red blood cell administration 36 (20.8) Hepatic repair or resection 1/63 (1.6)
Mean packed red blood cell units, No. 5.2 Intestinal resection or repair 6/63 (9.5)
Thawed plasma administration 19 (11.0) Arterial shunting or repair 12/63 (19.0)
Mean thawed plasma units, No. 5.6 External fixator extremity 7/173 (4.0)
Fluid or blood warming device use 10 (5.8) Burn debridement 1/63 (1.6)
Drug administration Extremity fasciotomy 6/63 (9.5)
Fentanyl 32 (18.5) Neck exploration 3/63 (4.8)
Versed 19 (11.0) Complex wound debridement/washout 17/63 (27.0)
Ketamine 19 (11.0)
Morphine 27 (15.6) military casualties injured from September 2001 to March
Tranexamic acid 4 (2.3) 2014. They noted that, after adjustment for injury severity,
casualties who received a transfusion or were transferred to
Antibiotics 46 (26.6) DCS capability within an hour of injury were less likely to die
Other medication (i.e., paralytics, of combat-sustained wounds. The investigators estimated that
antiemetics, or not otherwise specified) 58 (33.5) the practice of delivering casualties to a DCS-capable environ-
Patient warming interventions 28 (16.2) ment in this time frame resulted in 359 lives saved over the
(external or internal)
a Blood product use reported in No. of units. study period. 9,10

significant difference in survival between patients intercepted However, most of the data from the Kotwal et al. study were
in less than 1 hour (31 of 33; 93.9%) or more than 1 hour collected during a period of robust military activity in a ma-
from injury (28 of 29; 96.6%; 1.81 [95% CI, 0.16–21.02]; ture combat theatre. As such, there existed a relatively devel-
P = .632). Patients intercepted in less than 1 hour ultimately oped casualty evacuation capability and a medical “footprint”
did require fewer total mean units of PRBCs (3.9 versus 5.9 designed to optimally position Role 2 and Role 3 MTFs to
units; 1.83 [95% CI, −1.79 to 5.83]; P = .283), and mean units achieve delivery of a casualty to resuscitative and DCS capa-
of thawed plasma (1.5 versus 5.3 units; 1.82 [95% CI, −0.62 bilities. More contemporary experience suggests that future
to 8.29]; P = .08), but these differences were not statistically military medical care may be required in less mature environ-
significant. ments, where distances to an established Role 2 DCS capabil-
ity may prove a greater challenge.
Discussion Additionally, the future construct of military resuscitation and
4
Recent experience in modern armed conflict has demonstrated DCS capabilities may be evolving. Traditional forward sur-
11
a continued need to optimize effective strategies to mitigate the gical elements are expensive to field, depend largely on the
risk for death due to bleeding on the battlefield. In particu- establishment of a robust supply chain, and are relatively large.
1–4
lar, an emerging appreciation of noncompressible torso hem- Additionally, the traditional forward surgical teams of various
1
orrhage (NCTH) as a cause of potentially preventable death military services are not capable of movement, due to larger
has driven critical examination of combat casualty care prac- footprints and bulky requirements, within the very short times
tices. Proposed strategies to combat NCTH on the battlefield potentially required to effectively respond to distant emergent
4
have included optimization of prehospital resuscitation with contingencies. Although more mobile resuscitative prehospital
5–7
blood products and the ability to control NCTH in the ear- capabilities, such as the UK Medical Response Team, were de-
liest phases after by expedient surgical intervention or other veloped during recent conflicts, 14,15 these units offer only non-
means. 1,8 surgical resuscitative capabilities and require the support of a
larger medical evacuation footprint. These specific units are not
A 2009 Secretary of Defense mandate established a desired designed to be used flexibly to support contingency situations
golden hour standard for the delivery of combat casualties to in various environments outside their tightly defined roles.
an environment capable of DCS intervention. A subsequent
review reported by Kotwal and colleagues 9,10 retrospectively We describe the experience of an SRT designed specifically
examined the effects of this time-sensitive intervention on for rapid and flexible response to emerging contingencies
subsequent combat casualty outcomes from military action in various roles. This unit can effectively bridge the gap be-
in Afghanistan. The investigators examined data from 21,089 tween TCCC and definitive surgical care in various settings.

70 | JSOM Volume 17, Edition 4/Winter 2017