Page 144 - JSOM Fall 2022

challenge hemostatic junctional wounds. Conclusion: Our findings Efficacy of Commercial Chest Seal Adherence
highlight the difficulty of controlling hemorrhage from junctional and Tension Pneumothorax Prevention:
wounds with hemostatic gauze in the context of prolonged field A Systematic Review of Quantitative Studies
care and casualty transport. Our research can guide selection of Roland Paquette, Meredith Quinene, Lorne H. Blackbourne,
hemorrhage control gauze when patients have prolonged field ex­ Paul B. Allen
traction or difficult transport. Our data demonstrates the frequency J Spec Oper Med. Fall 2021;21(3):78–85.
of junctional wound rebleeding after movement and thus the im­
portance of frequent patient reassessment. Background: Penetrating thoracic injuries account for an essential
subset of battlefield and civilian injuries that result in death. Cur­
Determining a Need for Point-of-Care Ultrasound rent recommendations are to use commercially available nonocclu­
in Helicopter Emergency Medical Services Transport sive chest seals. We review current evidence for which chest seal(s)
Timothy J. Lenz, Mary Beth Phelan, Tom Grawey is likely to be the most effective in treating open pneumothoraces.
Air Med J. 2021;40(3):175–178. Methods: A systematic review was conducted in accordance with
the PRIMSA 2009 standard systematic review methodology, ex­
Objective: Point­of care­ultrasound (PoCUS) is useful in evaluat­ cept where noted. The databases Pubmed, MEDLINE, CINAHL,
ing unstable emergency department patients. The portability of Scopus, and gray sources were searched for all English­language,
this technology increases its potential use in prehospital settings, full­manuscript, experimental, quantitative studies of humans and
including helicopter emergency medical services (HEMS) pro­ animals concerning seal adherence or their efficacy at preventing
grams. Identifying useful applications may support implementing tension pneumothoraces published between 1990 and 2020. A
a PoCUS program that develops sonography skills for prehospital numerical analysis was used to provide the consensus recommen­
providers. The aim of this study was to determine the HEMS pa­ dation. Results: Of 683 eligible identified articles [PubMed 528
tient population that would benefit from prehospital PoCUS for (77.3%), Scopus 87 (12.7%), CINAHL 67 (9.8%), one (0.1%) un­
hypotension and how commonly the extended focused assessment published], six (0.9%) articles were included. Synthesis of all stud­
with sonography in trauma (E­FAST) for trauma patients or the ies’ results suggested a consensus recommendation for the Hyfin
rapid ultrasound in shock (RUSH) for medical patients could be Vent Chest Seal and Russell Chest Seal. These two were the most
used by HEMS. Methods: A retrospective chart review was per­ effective chest seals, as previously investigated in a quantifiable, ex­
formed over a 1­year period of adult patients transported by a perimental study. Conclusion: While chest seals are recommended
midwestern HEMS system. Charts were reviewed for episodes in civilian and military prehospital medicine to improve patient
of hypotension. Results: The chart review included 216 charts, survival, current evidence concerning the individual device’s effi­
of which 3 were excluded. Of the 213 cases, 100 were trauma cacy is limited. Further scientific, quantitative research is needed to
patients, and 113 were medical patients. Of the trauma patients, clarify which commercially available chest seals are most effective
51% experienced hypotension, as did 73 of 113 medical patients. and provide patients with penetrating chest trauma the best possi­
Conclusion: Fifty percent of HEMS patients may benefit from ble method for preventing or mitigating tension pneumothoraces.
PoCUS to evaluate for hypotension in flight.
Blood Product Administration During Transport
Ketamine Use in Operation Enduring Freedom Throughout the US Africa Command Theater of Operation
Eric Leslie, Eric Pittman, Brendon Drew, Benjamin Walrath Steven G. Schauer, Jason F. Naylor, Andrew D. Fisher,
Mil Med. 2021;186(7­8):e720–e725. Darren G. Hyams, Brandon M. Carius, Mireya A. Escandon,
Carlissa D. Linscomb, Harry McDonald, Andrew P. Cap,
Introduction: Ketamine is a dissociative anesthetic increasingly James Bynum
used in the prehospital and battlefield environment. As an anal­ J Spec Oper Med. Fall 2021;21(3):66–70.
gesic, it has been shown to have comparable effects to opioids.
In 2012, the Defense Health Board advised the Joint Trauma Sys­ Background: United States Africa Command (US AFRICOM) is
tem to update the Tactical Combat Casualty Care Guidelines to one of six US Defense Department’s geographic combatant com­
include ketamine as an acceptable first line agent for pain con­ mands and is responsible to the Secretary of Defense for military
trol on the battlefield. The goal of this study was to investigate relations with African nations, the African Union, and African
trends in the use of ketamine during Operation Enduring Free­ regional security organizations. A full­spectrum combatant com­
dom (OEF) and Operation Freedom’s Sentinel (OFS) during the mand, US AFRICOM is responsible for all US Department of De­
years 2011–2016. Materials and Methods: A retrospective review fense operations, exercises, and security cooperation on the African
of Department of Defense Trauma Registry (DoDTR) data was continent, its island nations, and surrounding waters. We seek to
performed for all patients receiving ketamine during OEF/OFS characterize blood product administration within AFRICOM
in 2011–2016. Prevalence of ketamine use, absolute use, mecha­ using the in­transit visibility tracking tool known as TRAC2ES
nism of injury, demographics, injury severity score, provider type, (TRANSCOM Regulating and Command & Control Evacua­
and co­administration rates of various medications and blood tion System). Methods: We performed a retrospective review of
products were evaluated. Results: Total number of administra­ TRAC2ES medical evacuations from the AFRICOM theater of
tions during the study period was 866. Ketamine administration operations conducted between 1 January 2008 and 31 December
during OEF/OFS increased during the years 2011–2013 (28 pa­ 2018. Results: During this time, there were 963 cases recorded in
tient administrations in 2011, 264 administrations in 2012, and TRAC2ES originating within AFRICOM, of which 10 (1%) cases
389 administrations in 2013). A decline in absolute use was noted received blood products. All patients were males. One was a De­
from 2014 to 2016 (98 administrations in 2014, 41 administra­ partment of State employee, one was a military working dog, and
tions in 2015, and 46 administrations in 2016). The frequency the remainder were military personnel. Of the ten humans, seven
of battlefield ketamine use increased from 0.4% to 11.3% for were the result of trauma, most by way of gunshot wound, and
combat injuries sustained in OEF/OFS from 2011 to 2016. Ex­ three were due to medical causes. Among human subjects receiving
plosives (51%) and penetrating trauma (39%) were the most blood products for traumatic injuries, a total of 5 units of type O
common pattern of injury in which ketamine was administered. negative whole blood, 29 units of packed red blood cells (pRBCs),
Ketamine was co­administered with fentanyl (34.4%), morphine and 9 units of fresh frozen plasma (FFP) were transfused. No sub­
(26.2%), midazolam (23.1%), tranexamic acid (12.3%), plasma jects underwent massive transfusion of blood products, and only
(10.3%), and packed red blood cells (18.5%). Conclusion: This one subject received pRBCs and FFP in 1:1 fashion. All subjects
study demonstrates increasing use of ketamine by the US military survived until evacuation. Conclusion: Within the TRAC2ES da­
on the battlefield and effectiveness of clinical practice guidelines tabase, blood product administration within AFRICOM was in­
in influencing practice patterns. frequent, with some cases highlighting lack of access to adequate

140 | JSOM Volume 22, Edition 3 / Fall 2022