Page 91 - JSOM Winter 2021

If CEUS is used in penetrating abdominal injuries caused by prehospital, trauma, hemorrhagic shock, optimal timing, opti-
gunshot or stabbing typical findings have to be considered. mal dose, safe volume, incidence of venous thromboembolism
Material and methods: We report a case of gunshot wound of (VTE), IM bioavailability. Results: In total, 186 studies were
the liver during military mission in Afghanistan and a case of reviewed. The strength of the available data was variable, and
stab wound by knife of the left kidney. FAST was done in liver ranged from laboratory research, case reports, retrospective
gunshot as first diagnostic imaging. CEUS was performed ad- observational reviews, with few prospective studies. Cur-
ditionally in the emergency room (ER) by CX 50 Philips ultra- rent volume and concentrations of available formulations of
sound system and ultrasound contrast agent (UCA, SonoVue, TXA make it amenable to IM injection. Current best-practice
Bracco, Italy). CT scanning was performed after stabilization guidelines for large volume injection (i.e. 5cc) support IM ad-
in ER. CEUS was repeated during and after each following ministration in 4 locations in the adult human body. There is
operation. The stab wound to the kidney was a finding by now new data demonstrating complete bioavailability of IM
CEUS in a stable patient (Logiq E9 ultrasoundsystem, General TXA in both healthy subjects and those in hemorrhagic shock,
Electrics; UCA, SonoVue, Bracco, Italy). Active bleeding was with serum concentrations achieving antifibrinolysis in a clin-
excluded simultaneously. ically meaningful time. Conclusion: The available data on the
out-of-hospital use of TXA supports its use in hemorrhagic
Results: The extension of the gunshot to the liver could not
be estimated on first CEUS examination due to aerodermecta- shock, with maximal efficacy seen when TXA given as soon
sia and gas echo extended along the bullet track. Subsequent as possible from the point of injury. Studies on IM TXA are
CEUS after first operations revealed that the wound track echo limited, but the available data supports complete bioavailabil-
was unenhanced in majority. Follow-up CEUS effectively de- ity of IM TXA with peak concentrations sufficient to achieve
tected the wound tract, hematoma, and the liver area injured antifibrinolysis and in operationally meaningful time frames.
by the gunshot and could accurately reveal necrotic tissue in Balancing the available data and risk:benefit ratio, IM TXA
the injured area. should be considered a viable treatment option for tactical and
combat applications.
CEUS of the stabbed left kidney revealed a triangular area
without perfusion in the lower pole without extravasation Psychological Effects of Terrorist Attacks on
of UCA as sign of a probable active bleeding. A diagnostic Emergency Responders and Possibilities for
laparoscopy revealed abdominal hemorrhage. The subsequent Faster Detection
laparotomy located an injury of the renal capsule causing a Ulrich Wesemann, Oliver Hochfeld, Carolyn Rose,
retroperitoneal hematoma. CT scanning was done 4 days after Gerd Willmund, Chris Röhrich
the Operation to rule out an urinoma. Conclusions: Applica- Introduction: The prevalence rate for PTSD in emergency
tion of CEUS may provide important imaging for gunshot and service personnel (ESP) after terrorist attacks ranges between
stab wounds. But in gunshot injuries the diagnostic validity 1.3% and 16.5%, for anxiety disorders between 0.7% and
in the initial examination is reduced by gas echos along the 14%, and for major depression between 1.3% and 25.8%. This
bullet track. In contrast the stab wound is a sharp deep cut wide range is attributed to different intensities of the terrorist
and therefore the ultrasound examination is not hindered by attacks. The aim is to develop and validate a questionnaire to
entrapped air. Thus CEUS is an interesting diagnostic tool in reduce stigma and to optimize the detection rate of soldiers
blunt and penetrating trauma of the abdomen and may be an and ESP with deployment-related mental disorders by involv-
appropriate tool in between FAST and CT or instead of CT in ing their partners. Methods: The partners assessed the changes
the initial ER phase and in follow-ups. CEUS may spare time in the soldiers with mental disorders following deployment.
in ER and facilitate decision-making in case of mass casualties The answers were categorized through thematic analysis and
and may spare transport capacity in military missions.
then used to develop a questionnaire. The questionnaire asks
to rate the changes in the partners (soldiers) on a five-point
Intramuscular (IM) Tranexamic Acid (TXA) in Likert scale. In a pre-test, N = 47 partners of soldiers who
Tactical And Combat Settings: Data to Support had been stationed abroad in the past 12 months completed
IM TXA at the Point of Injury the questionnaire. Half of the soldiers were diagnosed with
Erik N. Vu, MSM, CCP, MD, FRCPC a mission-related mental disorder (n = 24) and the other half
(n = 23) were not. The presence/absence of mental disorders
Introduction: Uncontrolled hemorrhage remains a leading was verified through a psychiatric interview. Findings: Out
cause of preventable death in tactical and combat settings. of 33, the top 24 ranking items with a discriminatory power
Recent attention on the use of TXA as an adjunct in the man- >.5 were included in the final version of the questionnaire.
agement of hemorrhagic shock has resulted in investigations Cronbach’s alpha was.98. Preliminary cut-off values were cal-
into alternate routes of delivery. Balancing tactical priorities, culated by ROC analyses with a sensitivity and specificity of
maintaining situational awareness and the time and skill re- over 90% (AUC = .93). Conclusions: The main evaluation of
quired to obtain vascular access while under duress, the ques- the final test version is running now with a state and a trait
tion was raised as to the potential role for IM administration component. Cronbach’s alpha, a cut-off value as well as sen-
of TXA in the out-of-hospital setting, as soon as possible from sitivity and specificity are calculated. This approach actively
the point of injury. A working group for the Committee for addresses the greatest and most pressing problem currently
Tactical Emergency Casualty Care was established to review facing military psychology in the Bundeswehr. Nevertheless, it
the available evidence on this subject. Methods: Embase and is only one tool in a complex system of measures.
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Medline /PubMed databases were searched by professional
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medical librarians from the College of Physicians and Sur-
geons of British Columbia, Canada. These databases were se- Keywords: mental health; military psychology; military person-
quentially searched to assess for evidence on the use of TXA in nel; emergency responders; stigma; partners; health services
the following contexts, and/or using the following key words: accessibility
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