Page 143 - JSOM Fall 2022

fresh whole blood resuscitation was associated with a significant 18.9%, with more among support personnel (64.3%). Of 46
reduction in 6­hour mortality versus non­warm fresh whole blood non­suicide trauma fatalities, most died of blast injury (67.4%)
in combat casualties, with a dose­dependent effect. These findings followed by gunshot wound (26.1%) and multiple/blunt force in­
support warm fresh whole blood use for hemorrhage control as jury (6.5%). The leading mechanism of death was catastrophic
well as expanded study in military and civilian trauma settings. tissue destruction (82.6%). Most had nonsurvivable injuries
(82.6%) and nonpreventable deaths (93.5%). Conclusion: Oper­
The Newest Battlefield Opioid, Sublingual Sufentanil: ation New Dawn fatalities were exclusively conventional forces
A Proposal to Refine Opioid Usage in the U.S. Military divided between combatants and support personnel, the former
Sharon Y. Kim, Chester C. Buckenmaier, Edmund G. Howe, succumbing more to battle injury and the latter to disease and
Kwang H. Choi nonbattle injury including self­inflicted injury. For non­suicide
Mil Med. 2022;187(3–4):77–83. 2021 Sep 29; online ahead trauma fatalities, none died from a survivable injury, and 17.4%
of print. died from potentially survivable injuries. Opportunities for im­
provement included providing earlier blood products and surgery.
There is an ongoing opioid epidemic in the USA, and the US mil­
itary is not immune to the health threat. To combat the epidemic, Level of evidence: Therapeutic, level V and epidemiological, level IV.
the Department of Defense (DoD) and Department of Veterans’
Affairs (DVA) issued new clinical practice guidelines and launched Exploring Tourniquet Conversion in Simulation
the Opioid Safety Initiative aimed at reducing opioid prescrip­ to Develop Concepts and Hypotheses
tions. Furthermore, the DoD continually refined opioid protocols John F. Kragh Jr, Tuan D. Le, Michael A. Dubick
for acute pain on the battlefield, evolving from intramuscular J Spec Oper Med. Fall 2021;21(3):23–29.
morphine to intravenous morphine administration to oral trans­ Background: Compared with those of tourniquet application, tour­
mucosal fentanyl citrate lollipops (Actiq) to finally sublingual niquet conversion concepts are underdeveloped. The purpose of this
sufentanil tablets (SSTs, Dsuvia). Interestingly, the newest intro­ project was to develop tourniquet conversion concepts and generate
duction of SSTs into the military sparked great controversy, as hypotheses. Methods: One person performed 100 tests of tourni­
there are concerns over the drug’s potential for misuse. However, quet application and conversion. Testing varied by conversion types,
although the opioid crisis may understandably foster an aversion materials, and assessments. Conversions were from improvised or
to new candidate opioids, the therapeutic benefits of effective Combat Application Tourniquets (C­A­T) to another C­A­T, a new
opioids in acute trauma settings should not be overlooked. SSTs site (with initial C­A­T only), a pneumatic Emergency and Military
may offer an improved analgesic option to meet the battlefield’s Tourniquet (EMT), or a pressure dressing (compression bandage
unmet needs with its non­invasive, sublingual delivery system and or a roll gauze and an elastic wrap). Simulated limbs were created
favorable pharmacologic properties that mitigate the risk for side using plastic bottle­based manikins, pool noodle­based manikins,
effects, addiction, and adverse outcomes. Accordingly, this com­ plastic pipes, glass bottles, a rain downspout, and a cardboard
mentary aims to (1) review the evolution of opioid use on the poster tube. Results: Tourniquet application, conversion, and total
battlefield and discuss the medical benefits and limitations of SSTs times averaged 105, 132, and 237 seconds, respectively. Improvised
in acute trauma settings, (2) highlight the importance of chronic tourniquet time was longer than that of C­A­T (p ≤ 0.05, all three).
pain management post­deployment through evidence­based non­ By initial tourniquet site, the 2–3 inches site had longer conver­
opioid modalities, and (3) explore avenues of future research. Ulti­ sion and total time (p ≤ 0.02, both) compared with highest site.
mately, we propose that SSTs are an important improvement from By whether initial tourniquets placed were also used in conversion,
existing battlefield opioids and that refining, not abandoning, opi­ total time was shorter if yes (p = 0.05). Conversion to a pressure
oid usage will be key to effectively managing pain in the military.
dressing was longer in conversion and total time (p ≤ 0.02, both)
compared with conversion to a tourniquet. One wrap was short; we
United States Military Fatalities switched to those longer to cover limbs better. Limb types varied for
During Operation New Dawn indentation. Conversion communications improved when we used
Russ S. Kotwal, Edward L. Mazuchowski, Jud C. Janak, abbreviations and symbols. Conclusion: This preliminary project
Jeffrey T. Howard, Howard T. Harcke, John B. Holcomb, simulated tourniquet conversion to develop clinical concepts and
Brian J. Eastridge, Jennifer M. Gurney, Stacy A. Shackelford research hypotheses to build a better basis for later research.
J Trauma Acute Care Surg. 2021;91(2):375–383.
Background: Military operations vary by scope, purpose, and in­ Efficacy of Hemostatic Gauzes in a Swine Model
tensity, each having unique forces and actions to execute a mis­ of Prolonged Field Care With Limb Movement
sion. Evaluation of military operation fatalities guides current Grace D. Landers, Cassandra Townsend, Micah Gaspary,
and future casualty care. Methods: A retrospective study was con­ Ryan Kachur, Brian Thorne, Sean Stuart, Jose Henao,
ducted of all US military fatalities from Operation New Dawn Gregory J. Zarow, Ramesh Natarajan, Michael Boboc
in Iraq from 2010 to 2011. Data were obtained from autopsies Mil Med. 2021;186(Suppl 1):384–390.
and other records. Population characteristics, manner of death, Introduction: Prolonged field care for junctional wounds is chal­
cause of death, and location of death were analyzed. All fatali­ lenging and involves limb movement to facilitate transport. No
ties were evaluated for concomitant evidence of underlying ath­ studies to date have explored the efficacy of gauze products to
erosclerosis. Non­suicide trauma fatalities were also reviewed for limit rebleeding in these scenarios. Materials and Methods: We ran­
injury severity, mechanism of death, injury survivability, death domly assigned 48 swine to QuikClot Combat Gauze, ChitoGauze,
preventability, and opportunities for improvement. Results: Of NuStat Tactical, or Kerlix treatment groups (12 each) and then
74 US military Operation New Dawn fatalities (median age, 26 inflicted a severe groin injury by utilizing a modified Kheirabadi
years; male, 98.6%; conventional forces, 100%; prehospital, model of a 6­mm femoral artery punch followed by unrestricted
82.4%) the leading cause of death was injury (86.5%). The man­ bleeding for 60 seconds. We reassessed rebleed following limb
ner of death was primarily homicide (55.4%), followed by suicide movement at 30 minutes of stabilization and 4 hours after stabili­
(17.6%), natural (13.5%), and accident (9.5%). Fatalities were zation. Results: Swine treated with Combat Gauze proved to have
divided near evenly between combatants (52.7%) and support the lowest incidence of rebleeding, and conversely, NuStat Tactical
personnel (47.3%), and between battle injury (51.4%) and dis­ had the highest incidence of rebleeding at wounds after limb move­
ease and nonbattle injury (48.6%). Natural and suicide death was ment. Importantly, rebleeds occurred at a rate of 25–58% across all
higher (p < 0.01, 0.02) among support personnel who were older swine treatment groups at 30 minutes postinjury and 0–42% at 270
(p = 0.05) with more reserve/national guard personnel (p = 0.01). minutes postinjury, demonstrating that limb movements universally
Total population prevalence of underlying atherosclerosis was

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