Page 174 - JSOM Spring 2018

concern about the potential for exacerbation of hemorrhage at
bleeding sites proximal to the site of aortic occlusion with the
AAJT. Similar concerns apply to Zone III REBOA.

17. Management of Suspected Tension Pneumothorax in
TCCC: Dr Frank Butler discussed the pending proposed change
to the TCCC Guidelines on the management of suspected ten-
sion pneumothorax in the prehospital setting. Recent literature
on that topic was reviewed, as were clinical findings from the
JTS Performance Improvement Process and the Armed Forces
Medical Examiner Autopsy Review series. The working group
preparing this proposed change will use this information to
answer the relevant questions listed below:
– When should a tension pneumothorax be suspected?
– What device should be used for needle decompression
(NDC)?
– What anatomical site is the preferred location for NDC?
– What technique should be used for NDC?
– How can the medic tell if the NDC has been successful?
– What should be done if the initial NDC is not successful?
– What should be done if the initial NDC is successful, but
symptoms recur?
– What should be done if repeated NDC fails to produce im-
provement in the casualty?

The working group for this proposed change will continue
their review and use the information to draft a proposed
change to the TCCC Guidelines on this topic.

18. TCCC Maritime: CAPT Jose Acosta is a trauma surgeon,
the former Commander of Naval Medical Center San Diego
and now the Third Fleet Surgeon. In discussing how TCCC
applies to ships at sea, he reviewed a number of historical ex-
amples of shipboard mass casualty events:
mechanism of injury (50); faster transport time (137); body – USS Franklin
region (185); prehospital blood transfusion (236); and unex- – USS Stark
plained (20). Collectively, the changes in injury patterns and – USS Cole
improvements in care resulted in an estimated 597 American – USS Fitzgerald
lives saved during this time period.
He noted that shipboard casualties entail significantly different
16. A Relook at the Abdominal Aortic and Junctional Tourni- epidemiology of wounding and death, as exemplified by this
quet (AAJT): Dr Jonny Morrison, now an attending physician quote from the VFW Magazine in 2013 about the 37 fatalities
at the R. Adams Cowley Shock/Trauma Center in Baltimore, in the USS Stark casualty incident: “Most who died did so in
reviewed the emerging literature concerning the use of the their bunks—burned or suffocated. The crew’s quarters became
AAJT to treat trauma patients in the prehospital setting. Dr an inferno, reaching 400 degrees.” A Journal of Trauma report
Morrison reviewed the findings in the studies by Rall and col- on the 17 fatalities that resulted from the terrorist attack on the
leagues at the 59th Medical Wing and Kheirabadi and col- USS Cole categorized 15 of the 17 deaths as “unsurvivable.” Of
leagues at the USAISR. The findings can be summarized as note, three of the fatalities who were classified as unsurvivable
follows: 1) the AAJT appears to be effective at controlling died from drowning. In the 2017 USS Fitzgerald collision, all 7
pelvic hemorrhage; 2) it is as effective as REBOA at occlud- of the resulting fatalities were found by the Armed Forces Medi-
ing the abdominal aorta; and 3) it is associated with a similar cal Examiner System to be caused by drowning. CAPT Acosta
reperfusion injury. concluded that there is presently an opportunity to integrate
Two case reports of AAJT use were discussed. In the first, maritime casualty concepts into TCCC and that casualty train-
the device was applied for a casualty who was pulseless from ing in the US Navy must be kept current and relevant.
hemorrhagic shock caused by bilateral lower extremity inju-
ries despite tourniquet application. The AAJT was reported 19. TCCC Curricula 2017 and PHTLS 9: Dr Stephen Giebner,
to cause clinical improvement and the patient survived. In the the CoTCCC Developmental Editor, reviewed the progress on
second case, the AAJT was used successfully to control bleed- the 2017 updates to the TCCC for Medical Personnel (MP)
ing from an injured axillary artery. and the TCCC for All Combatants (AC) curricula.
Dr Morrison and his colleagues published a study in This year’s update is based on the on the TCCC Guidelines
Shock in 2014 that found that approximately 20% of severely dated 170131 and has 229 files, comprising 2.22 GB of mate-
injured UK combat casualties had injuries with hemorrhage rial. It includes changes 16-02 (Pelvic Binders) and 16-03 (TCCC
in the abdomen or pelvic junctional region. These casual- Guidelines Comprehensive Review and Update) as well as the
ties might benefit from treatment with the AAJT, but there is newly developed TCCC Critical Decision Case Studies.

168 | JSOM Volume 18, Edition 1/Spring 2018