Page 79 - JSOM Fall 2020

is a retrospective review of prospectively collected data within Results
the registry. As only US military Servicemembers receive and
use the CWMP, we removed all non-US military casualties During the study period, there were a total of 38,769 encoun-
from this analysis. We searched our dataset for all subjects ters in the DODTR. Our predefined search codes captured
who had documentation of receipt of a CWMP or adminis- 28,222 (72.8%) of these casualties. Of the 28,222 casualties,
tration of one or more of the three components of the CWMP we included the 11,665 (41.3%) who were US military service
(oral acetaminophen, meloxicam, moxifloxacin). We did not members. Of those, 84 (0.7%) met inclusion as recipients of
categorize patients as recipients of individual CWMP compo- one or more components of the CWMP. Of these, 6 (7.1%)
nents if they received these drugs via routes of administration were included by way of direct documentation of the CWMP.
other than oral (e.g., intravenous moxifloxacin). The remaining subjects were included by way of documen-
tation of one or more of the following: acetaminophen (71),
We chose the following TCCC-based inclusion criteria for as- meloxicam (13) moxifloxacin (6). Subject characteristics were
sessing adherence as these were discernible within our dataset: similar between nonrecipients and recipients including me-
gunshot wounds, tourniquet applications, major amputations, dian age, (24 versus 24), percent of male subjects (97% versus
open fractures, and serious injuries by abbreviated injury scale 100%), and percent sustaining injuries from explosives (62%
to the thorax, abdomen, or extremities. 14 versus 64%), and percent sustained injuries from gunshot
wounds (15% versus 17%). Median composite injury scores
were higher for nonrecipients versus recipients (6 versus 4, P <
Ethics
The US Army Institute of Surgical Research regulatory office .001). Nonrecipients had lower proportions of serious injury
reviewed protocol H-16-005 and determined it was exempt to the head/neck and extremity body regions (Table 1).
from institutional review board oversight. We obtained only
deidentified data. Among subjects with a gunshot wound, <1% (14 of 1805)
received the CWMP. Among those with a tourniquet applied,
<1% (11 of 1912) received the CWMP. Among those with
DODTR Description
The DoDTR, formerly known as the Joint Theater Trauma a major amputation, <1% (5 of 803) received the CWMP.
Registry (JTTR), is the data repository for the DoD of trau- Among those with an open fracture, <1% (10 of 2425) re-
ma-related injuries.[ 3,15–18 The DoDTR includes documentation ceived the CWMP (Table 2). Based on serious injuries by body
regarding demographics, injury-producing incidents, diagno- region, we had similar findings for the thorax (<1%, 3 of
ses, treatments, and outcomes following injuries. The registry 1122), abdomen (<1%; 1 of 736), and extremities (<1%; 11
includes US/non-US military and US/non-US civilian person- of 2699; Table 3).
nel from the point of injury to final disposition during war
and peacetime. The DoDTR comprises patients admitted to a Discussion
Role 3 (fixed-facility) or forward surgical team (FST) with an
injury diagnosis using the International Classification of Dis- Our study is unique in evaluating the administration of
ease, 9th Edition (ICD-9) between 800–959.9, near-drowning/ CWMP and its constituent components among all US forces
drowning with associated injury (ICD-9 994.1) or inhalational in Iraq and Afghanistan. Compared to nonrecipients, subjects
injury (ICD-9 987.9), and trauma occurring within 72 hours who received CWMP were predominantly casualties from Af-
from presentation to a facility with surgical capabilities. The ghanistan, and with significantly lower injury severity scores.
DoDTR defines prehospital as any location prior to reaching We found that CWMP administration was rare. Even among
a forward surgical team (FST) or a combat support hospital those subjects with documentation of injury patterns meeting
(CSH) to include the Role 1 (point of injury, casualty collection TCCC guideline criteria for CWMP experienced probabilities
point, battalion aid station) and Role 2 (traditional definition, of receipt under 1%.
temporary limited-capability forward-positioned hospital in-
side combat zone without surgical support). A joint Role 2, Subjects that received CWMP agents were less severely in-
captured as Role 2e in the registry, has surgical capabilities jured. TCCC guidelines recommend CWMP analgesics for ca- 4
and is not considered prehospital within the registry. sualties with mild to moderate pain who are still able to fight.
Consequently, our finding of CWMP administrations to less
severely injured subjects is consistent with TCCC indications
Analysis
We performed all statistical analyses using Microsoft Excel for CWMP analgesia. However, TCCC guidelines also recom-
19
(version 10, Redmond, WA) and JMP Statistical Discovery mend the CWMP antibiotic for all open wounds. More than
from SAS (version 13, Cary, NC). We compared characteris- 75% of nonrecipients suffered explosive injuries and gunshot
tics of combat casualties not receiving CWMP to those who wounds, with more than a third sustaining severe injury to
did receive this intervention. Specifically, we compared subject the extremities and thorax. The vast majority of these sub-
demographics, injury patterns, and incidence of severe inju- jects likely qualified for prehospital wound prophylaxis and
ries. We categorized injuries as serious if the abbreviated injury did not receive it. This finding may in part reflect that fact that
score by body region was 3 or greater. We compared study many of these casualties were poor candidates for oral medi-
variables using a t-test for continuous variables expressed cations and so received antibiotics (and analgesics) by another
as means with standard deviations, Wilcoxon rank sum test route of administration. However, previous analyses demon-
for ordinal variables expressed as medians and interquartile strate low rates of parental analgesia and wound prophylaxis,
8,20,21
ranges, and χ test for nominal variables expressed as num- which contradicts this reason for nonadministration. It
2
bers and percentages. We also calculated the proportions of is possible that prehospital providers may have subordinated
proportions of casualties with injury patterns consistent with antimicrobial administration to interventions required more
TCCC guideline indications for CWMP use who received this immediately to treat life-threatening injuries, though that is
22–25]
intervention. 14 not supported by previous analyses.
Prehospital Combat Wound Medication Pack Administration | 77