Page 23 - JSOM Summer 2022

use of External Aortic Compression (EAC), with the providers FIGURE 7 CDR Joe Kotora, 2 Marine Division Surgeon, supervises
applying strong pressure just superior to and slightly to the a fresh whole blood training exercise.
left of the patient’s umbilicus. 56,57 This technique has not been
widely used, but has been associated with at least temporary
benefit in two published cases – one in the emergency depart-
59
ment and one in the prehospital setting. 58
The primary concerns regarding aortic occlusion at the bifur-
cation with all three of the techniques noted above is that, if
there is an injured blood vessel or solid organ (e.g., liver or
spleen) whose blood supply is provided by an artery originat-
ing between the heart and the aortic occlusion, the bleeding (USMC Photo by Gunnery Sgt Leon Branchaud)
will be made worse. 28,60 A 2018 study found that of 402 pa-
tients undergoing emergency trauma laparotomy, the bleeding
sites identified at surgery were such that only 9% of patients
would have benefitted from the three options for abdomi-
nopelvic hemorrhage control noted above. 60
A fourth option for controlling abdominopelvic bleeding in
the prehospital setting – if and when it is approved by the make badly needed fresh whole blood available for transfu-
FDA – would be a developmental product called ResQFoam. sion much sooner than waiting until the casualties arrive at
In this device, two polymer precursors are injected into the the LHA.
peritoneal cavity. The products mix during injection and then
expand, and in doing so, apply pressure to intra-abdominal As noted above, the embarked Marine Corps STP is a readily
bleeding sites. ResQFoam has performed well in animal stud- available source of additional medical personnel to assist in the
ies, successfully controlling bleeding in both hepatoportal and care of the casualties before and during transport to the LHA.
external iliac artery bleeding models. 61-63 Preclinical safety The STP Emergency Medicine physician also has the expertise
studies of ResQFoam with 90-day survival periods have also and the equipment to provide advanced airway and ventila-
been conducted to determine the optimal dosing of the foam tion support to the casualties who may need those interven-
precursors. At present, however, clinical trials are still being tions. The equipment assemblage in the STP currently includes
conducted on ResQFoam and it has not yet received FDA Zoll Impact Uni-Vent 731 ventilators, intubation equipment,
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approval. The Cantle study found that ResQFoam would Propaq monitors, suction devices, litters, and drop-down bags
likely have been effective in achieving pre-surgical hemorrhage with consumables (IV kits, medications, etc.).
control in 87% of patients requiring an emergent trauma
laparotomy. 60 Underwater Blast Injury Pattern
Primary blast wave injuries may include ruptured tympanic
A fifth option for prehospital control of abdominopelvic NCTH membrane, pulmonary injuries (pneumothorax, pulmonary
is Resuscitative Endovascular Balloon Occlusion of the Aorta contusions, interstitial and subcutaneous emphysema, and
(REBOA). This option was discussed in the 2018 TCCC Ad- pneumomediastinum) as well as injuries to the brain, eyes,
vanced Resuscitation Care paper. REBOA might be useful in a heart, and gastrointestinal tract. 65,66 Primary blast wave in-
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casualty scenario such as this, but that capability is not feasible juries may be easily missed during triage because the initial
on a small combatant ship such as a destroyer. REBOA could, manifestations can be subtle and because blast casualties often
however, be performed by an advanced resuscitation team that present in a mass casualty setting. 66
has been trained and equipped to perform prehospital REBOA,
as outlined in the ARC paper. The Cantle study found that Casualties 6, 7, and 8 all have injuries sustained from expo-
Zone 1 REBOA could have worked effectively in 96% (384 of sure to a nearby underwater explosion. This injury pattern is
402) of the trauma laparotomy patients in that study. 60 uncommon, as the US Navy has not engaged in a major battle
between surface combatant vessels since the Battle of Leyte
Enhancing Treatment Capability During Shipboard Gulf in October of 1944. 67
Mass Casualties With Embarked US Marine Corps Units Underwater blast injuries, however, were well-described in
Since most preventable deaths among combat casualties occur past combat actions wherein individuals immersed in the wa-
prior to the casualty reaching a surgical care capability (in this ter were exposed to a nearby underwater explosion. 41,42 In such
case, the surgical team located on the LHA), enhancing the a circumstance, the physiologic impact of the primary blast
medical care provided prior to arrival at the LHA is critical to wave is greatly magnified by the non-compressibility of water.
improving survival. Considering that most amphibious task The gas-containing organs of the body (lungs, gastrointestinal
forces will have Marine Corps units embarked on large deck tract, and ears) are the most severely affected. Pulmonary in-
amphibious ships such as an LHA, one readily available way jury is usually the predominant source of morbidity and mor-
to improve care in scenarios such as this one is to make opti- tality from severe primary blast wave trauma. 68,69 Air emboli in
mal use of the medical capability embodied in the embarked the arterial circulation from intra-alveolar or peri-bronchiolar
Marine Corps units.
damage are responsible for most early mortality. Although
69
Both I and II Marine Expeditionary Force units at this point abdominal injury from primary blast wave trauma is possible
in time are establishing LTOWB Walking Blood Banks, based with exposure to a blast wave in air, it is more likely to occur
70
on the Valkyrie program pioneered by LCDR Russ Wier 35,64 in underwater blast injury. Injury to the large bowel predom-
(Figure 7). Employing that capability as described above and inates, but splenic or hepatic ruptures with intra- abdominal
transporting the blood obtained to the casualty ship would hemorrhage are possible, though uncommon. 68–70

TCCC Maritime Scenario: Shipboard Missile Strike | 21