Page 142 - JSOM Fall 2022

expert panel review of AARs within the PHTR in Afghanistan from Care (TCCC) guidelines prescribe a bolus of 3% or 5% hypertonic
January 2013 to September 2014. When possible, we categorized saline. However, this fluid bears a tactical burden of weight (~570 g)
3
our findings and selected relevant medical provider comments. Re- and pack volume (~500 cm ). Thus, 23.4% hypertonic saline is an
sults: Of 737 registered patient encounters found, 592 (80%) had attractive option, because it has a lighter weight (80 g) and pack
3
AAR documentation. Most AAR patients were male (98%, n = volume (55 cm ), and it provides a similar osmotic load per dose.
578), injured by explosion (48%, n = 283), and categorized for ur­ Current literature supports the use of 23.4% hypertonic saline in
gent evacuation (64%, n = 377). Nearly two thirds of AARs stated the management of acute TBI, and evidence indicates that it is safe
areas needing improvement (64%, n = 376), while the remainder to administer via peripheral and intraosseous cannulas. Current
left the improvement section blank (23%, n = 139) or specified no combat medic TBI treatment algorithms should be updated to in­
improvements (13%, n = 76). The most frequently cited areas for clude the use of 23.4% hypertonic saline as an alternative to 3%
improvement were medical knowledge (23%, n = 136), evacuation and 5% solutions, given its effectiveness and tactical advantages.
coordination (19%, n = 115), and first responder training (16%,
n = 95). Conclusion: Our expert panel reviewed AARs within the A Case Study of Long-Range Rotary Wing Critical Care
PHTR and found substantial numbers of AARs without improve­ Transport in the Battlefield Environment
ments recommended, which limits quality improvement capabili­ Jamie Eastman, Jennifer Dumont, Kelly Green
ties. Our analysis supports previous calls for better documentation J Spec Oper Med. Summer 2021;21(2):77–79.
of medical care in the prehospital combat setting.
Military medical evacuation continues to grow both in distance
Evaluation of the Efficacy of Commercial and and transport times. With the need for long­range transport of
Noncommercial Tourniquets for Extremity Hemorrhage greater than two hours, crews are having to manage critical care
Control in a Perfused Cadaver Model patients for longer trips. This case study evaluates one specific
Camilla Cremonini, Nadya Nee, Matthew Demarest, event in which long­range transport of a sick noncombat patient re­
Alice Piccinini, Michael Minneti, Catherine P. Canamar, quired an enroute critical care team. Medical electronics and other
Elizabeth R. Benjami, Demetrios Demetriades, Kenji Inaba equipment require special attention. Oxygen bottles and batteries
J Trauma Acute Care Surg. 2021;90(3):522–526. for medical devices become the limiting factor in transport from
point to point. Having to juggle multiple data streams requires
Background: Tourniquets are a critical tool in the immediate re­ prioritization and reassessment of interventions. Using the mne­
sponse to life­threatening extremity hemorrhage; however, the op­ monic “bottles, bags, batteries, battlefield environment” keeps the
timal tourniquet type and effectiveness of noncommercial devices transport paramedic and enroute care nurse on track to effectively
remain unclear. Our aim was to evaluate the efficacy of five tour­ deliver the patient to the next level of care. Consideration should
niquets in a perfused­cadaver model. Methods: This prospective be given to such mnemonics for long critical care transports.
study used a perfused­cadaver model with standardized superficial
femoral artery injury bleeding at 700 mL/min. Five tourniquets Whole Blood at the Tip of the Spear:
were tested: combat application tourniquet; rapid application A Retrospective Cohort Analysis of Warm Fresh
tourniquet system; Stretch, Wrap, and Tuck Tourniquet; an im­ Whole Blood Resuscitation Versus Component Therapy
provised triangle bandage windlass; and a leather belt. Forty­eight in Severely Injured Combat Casualties
medical students underwent a practical hands­on demonstration Jennifer M. Gurney, Amanda M. Staudt, Deborah J. Del Junco,
of each tourniquet. Using a random number generator, they placed Stacy A. Shackelford, Elizabeth A. Mann-Salinas,
the tourniquets on the bleeding cadaver in random order. Time to Andrew P. Cap, Philip C. Spinella, Matthew J. Martin
hemostasis, time to secure devices, estimated blood loss, and diffi­ Surgery. 2022;171(2):518–525. Epub 2021 Jul 10.
culty rating were assessed. A one­way repeated measures analysis
of variance was used to compare efficacy between the tourniquets Background: Death from uncontrolled hemorrhage occurs rap­
in achieving the outcomes. Results: The mean ± SD participant idly, particularly among combat casualties. The US military has
age was 25 ± 2.6 years, and 29 (60%) were male. All but one used warm fresh whole blood during combat operations owing
tourniquet was able to stop bleeding, but the rapid application to clinical and operational exigencies, but published outcomes
tourniquet system had a 4% failure rate. Time to hemostasis and data are limited. We compared early mortality between casual­
estimated blood loss did not differ significantly (p > 0.05). Stretch, ties who received warm fresh whole blood versus no warm fresh
Wrap, And Tuck Tourniquet required the longest time to be se­ whole blood. Methods: Casualties injured in Afghanistan from
cured (47.8 ± 17.0 seconds), whereas the belt was the fastest (15.2 2008 to 2014 who received ≥ 2 red blood cell containing units
± 6.5 seconds; p < 0.001). The improvised windlass was rated were reviewed using records from the Joint Trauma System Role
easiest to learn and apply, with 22 participants (46%) assigning a 2 Data base. The primary outcome was 6­hour mortality. Pa­
score of 1. Conclusion: Four of five tourniquets evaluated, includ­ tients who received red blood cells solely from component ther­
ing both noncommercial devices, effectively achieved hemostasis. apy were categorized as the non­warm fresh whole blood group.
A standard leather belt was the fastest to place and was able to Non­ warm fresh whole blood patients were frequency­matched
stop the bleeding. However, it required continuous pressure to to warm fresh whole blood patients on identical strata by injury
maintain hemostasis. The improvised windlass was as effective as type, patient affiliation, tourniquet use, prehospital transfusion,
the commercial devices and was the easiest to apply. In an emer­ and average hourly unit red blood cell transfusion rates, creating
gency setting where commercial devices are not available, impro­ clinically unique strata. Multilevel mixed effects logistic regression
vised tourniquets may be an effective bridge to definitive care. were adjusted for the matching, immortal time bias, and other co­
variates. Results: The 1,105 study patients (221 warm fresh whole
23.4% Hypertonic Saline: A Tactical Option blood, 884 non­warm fresh whole blood) were classified into 29
for the Management of Severe Traumatic Brain Injury unique clinical strata. The adjusted odds ratio of 6­hour mortality
With Impending or Ongoing Herniation was 0.27 (95% confidence interval 0.13–0.58) for the warm fresh
Erik Scott DeSoucy, Kelsey Cacic, Brian P. Staak, whole blood versus non­warm fresh whole blood group. The re­
Christopher D. Petersen, David van Wyck, duction in mortality increased in magnitude (odds ratio = 0.15,
Venkatakrishna Rajajee, John Dorsch, Stephen C. Rush P = 0.024) among the subgroup of 422 patients with complete
J Spec Oper Med. Summer 2021;21(2):25–28. data allowing adjustment for seven additional covariates. There
was a dose­dependent effect of warm fresh whole blood, with pa­
There are limited options available to the combat medic for man­ tients receiving higher warm fresh whole blood dose (> 33% of red
agement of traumatic brain injury (TBI) with impending or ongo­ blood cell­containing units) having significantly lower mortality
ing herniation. Current pararescue and Tactical Combat Casualty versus the non­warm fresh whole blood group. Conclusion: Warm

138 | JSOM Volume 22, Edition 3 / Fall 2022