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advanced interventions and the casualty is in shock. These two platforms. However, documentation on casualty evacuation
more invasive procedures are recommended only when the ca- (CASEVAC) platforms is still lacking. Thus, a CASEVAC data-
sualty is in refractory shock, not as the initial treatment. set was developed and maintained by the 160th Special Oper-
ations Aviation Regiment (SOAR), a nonmedical, rotary-wing
Keywords: guidelines; tension pneumothorax; Tactical Com- aviation unit, to evaluate and review CASEVAC missions
bat Casualty Care
conducted by their organization. Methods: A retrospective re-
view and descriptive analysis were performed on data from
2018;18(1):62–68 all documented CASEVAC missions conducted in Afghanistan
Intramuscular Tranexamic Acid in Tactical and Combat Set- by the 160th SOAR from January 2008 to May 2015. Doc-
tings Vu EN, Wan WC, Yeung TC, Callaway DW umentation of care was originally performed in a narrative
ABSTRACT: Background: Uncontrolled hemorrhage remains after-action review (AAR) format. Unclassified, nonpersonally
a leading cause of preventable death in tactical and combat set- identifiable data were extracted and transferred from these
tings. Alternate routes of delivery of tranexamic acid (TXA), AARs into a database for detailed analysis. Data points in-
an adjunct in the management of hemorrhagic shock, are be- cluded demographics, flight time, provider number and type,
ing studied. A working group for the Committee for Tacti- injury and outcome details, and medical interventions pro-
cal Emergency Casualty Care reviewed the available evidence vided by ground forces and CASEVAC personnel. Results:
on the potential role for intramuscular (IM) administration There were 227 patients transported during 129 CASEVAC
of TXA in nonhospital settings as soon as possible from the missions conducted by the 160th SOAR. Three patients had
point of injury. Methods: EMBASE and MEDLINE/PubMed unavailable data, four had unknown injuries or illnesses, and
databases were sequentially searched by medical librarians for eight were military working dogs. Remaining were 207 trauma
evidence of TXA use in the following contexts and/or using casualties (96%) and five medical patients (2%). The mean
the following keywords: prehospital, trauma, hemorrhagic and median times of flight from the injury scene to hospital
shock, optimal timing, optimal dose, safe volume, incidence of arrival were less than 20 minutes. Of trauma casualties, most
venous thromboembolism (VTE), IM bioavailability. Results: were male US and coalition forces (n = 178; 86%). From this
A total of 183 studies were reviewed. The strength of the avail- population, injuries to the extremities (n = 139; 67%) were
able data was variable, generally weak in quality, and included seen most commonly. The primary mechanisms of injury were
laboratory research, case reports, retrospective observational gunshot wound (n = 89; 43%) and blast injury (n = 82; 40%).
reviews, and few prospective studies. Current volume and The survival rate was 85% (n = 176) for those who incurred
concentrations of available formulations of TXA make it, in trauma. Of those who did not survive, most died before reach-
theory, amenable to IM injection. Current best practice guide- ing surgical care (26 of 31; 84%). Conclusion: Performance
lines for large-volume injection (i.e., 5mL) support IM admin- improvement efforts directed toward prehospital combat ca-
istration in four locations in the adult human body. One case sualty care can ameliorate survival on the battlefield. Because
series suggests complete bioavailability of IM TXA in healthy documentation of care is essential for conducting performance
patients. Data are lacking on the efficacy and safety of IM improvement, medical and nonmedical units must dedicate
TXA in hemorrhagic shock. Conclusion: There is currently in- time and efforts accordingly. Capturing and analyzing data
sufficient evidence to support a strong recommendation for or from combat missions can help refine tactics, techniques, and
against IM administration of TXA in the combat setting; how- procedures and more accurately define wartime personnel,
ever, there is an abundance of literature demonstrating efficacy training, and equipment requirements. This study is an exam-
and safety of TXA use in a broad range of patient populations. ple of how performance improvement can be initiated by a
Balancing the available data and risk- benefit ratio, IM TXA nonmedical unit conducting CASEVAC missions.
should be considered a viable treatment option for tactical and Keywords: casualty evacuations; CASEVAC; en route care;
combat applications. Additional studies should focus on the Tactical Combat Casualty Care; TCCC
optimal dose and bioavailability of IM dosing of patients in
hemorrhagic shock, with assessment of potential downstream 2019;19(1):70–74
sequelae.
Battlefield Analgesia: Adherence to Tactical Combat Casualty
Keywords: intramuscular; tranexamic acid; hemorrhagic Care Guidelines Schauer SG, Fisher AD, April MD, Carter
shock; Tactical Combat Casualty Care; Tactical Emergency R, Cunningham CW, Aden JK, Fernandez JD, DeLorenzo RA
Casualty Care
ABSTRACT: Background: Low rates of prehospital analgesia,
as recommended by Tactical Combat Casualty Care (TCCC)
2018;18(2):79–85 guidelines, have been demonstrated in the Joint Theaters com-
Survey of Casualty Evacuation Missions Conducted by the bat setting. The reasons for this remain unclear. This study
160th Special Operations Aviation Regiment During the Af- expands on previous reports by evaluating a larger prehospital
ghanistan Conflict Redman TT, Mayberry KE, Mora AG, dataset for determinants of analgesia administration. Meth-
Benedict BA, Ross EM, Mapp JG, Kotwal RS ods: This was part of an approved quality assurance project
ABSTRACT: Background: Historically, documentation of evaluating adherence to TCCC guidelines across multiple
prehospital combat casualty care has been relatively nonex- modalities. Data were from the Prehospital Trauma Registry,
istent. Without documentation, performance improvement which existed from January 2013 through September 2014,
of prehospital care and evacuation through data collection, and comprises data from TCCC cards, Department of Defense
consolidation, and scientific analyses cannot be adequately 1380 forms, and after-action reports to provide real-time feed-
accomplished. During recent conflicts, prehospital documen- back to units on prehospital medical care. Results: Of 705 total
tation has received increased attention for point-of-injury care patient encounters, there were 501 documented administra-
as well as for care provided en route on medical evacuation tions of analgesic medications given to 397 patients. Of these
events, 242 (34.3%) were within TCCC guidelines. Special

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