Page 146 - JSOM Fall 2022

Objectives: The Tactical Combat Casualty Care (TCCC) guide­ NC), and the Special Operations Forces (SOF) Tactical Tourni­
lines detail resuscitation practices in prehospital and austere en­ quet­Wide (SOFTT­W; Tactical Medical Solutions, Anderson, SC).
vironments. We sought to review the content and quality of the Methods: This study was a three­phase randomized, cross­over
current TCCC and civilian prehospital literature and characterize trial. In successive trials, subjects were timed during the applica­
knowledge gaps to offer recommendations for future research. tion of each tourniquet to the upper and lower extremity. Follow­
Methods: MEDLINE, EMBASE, CINAHL, and Cochrane Cen­ ing successful lower extremity application, subjects low crawled
tral Register of Controlled Trials were searched for studies as­ 25 ft and then were dragged 25 ft, after which effectiveness was
sessing intervention techniques and devices used in civilian and reassessed, as defined by the cessation of distal pulses by Doppler
military prehospital settings that could be applied to TCCC guide­ ultrasound. Results: In arm application, both the CAT and TMT
lines. Screening and data extraction were performed according to had significantly less failure rates than the SOFTT­W (5.56%,
PRISMA (Preferred Reporting Items for Systematic Reviews and 19.44%, 58.33%), with the CAT being the fastest tourniquet
Meta­Analyses) guidelines. Quality appraisal was conducted using when compared with TMT and SOFTT­W (37.8 seconds, 65.01
appropriate tools. Results: Ninety­two percent (n = 57) of studies seconds, 63.07 seconds). In leg application, the CAT had signifi­
were observational. Most randomized trials had low risk of bias, cantly less rates of failure when compared with the SOFTT­W, but
whereas observational studies had higher risk of bias. Interven­ there was no other significant difference between the tourniquets
tions of massive hemorrhage control (n = 17) were wound dress­ (27.78%, 44.44%, 61.11%). In addition, the CAT was signifi­
ings and tourniquets, suggesting effective hemodynamic control. cantly faster than both the TMT and SOFTT­W when applied to
Airway management interventions (n = 7) had high success rates the leg (8.33 seconds, 40.96 seconds, 34.5 seconds). There was no
with improved outcomes. Interventions of respiratory manage­ significant difference in tourniquet failure rates between the three
ment (n = 12) reported low success with needle decompression. tourniquets after subject maneuvers in phase 3 (34.29%, 42.86%,
Studies assessing circulation (n = 18) had higher quality of evi­ 45.45%). Discussion: The CAT is as effective as the TMT and sig­
dence and suggested improved outcomes with component hemo­ nificantly more effective than the SOFTT­W. In addition, the CAT
static therapy. Hypothermia prevention interventions (n = 2) were demonstrated shorter application times than either the TMT or
generally effective. Other studies identified assessed the use of ex­ SOFTT­W. However, there was no significant difference between
tended focused assessment with sonography in trauma (n = 3) and the three tourniquets in their ability to maintain pulselessness after
mixed interventions (n = 2). Conclusion: The evidence was largely subject maneuvers.
non­randomized with heterogeneous populations, interventions,
and outcomes, precluding robust conclusions in most subjects The Role of Plasma Transfusion in Pre-Hospital
addressed in the review. Knowledge gaps identified included the Haemostatic Resuscitation
use of blood products and concentrate of clotting factors in the Harriet Tucker, Ross Davenport, Laura Green
prehospital setting. Transfusion Med Rev. 2021;35(4):91–95.
Between the Devil and the Deep Blue Sea: A Review of Traumatic hemorrhage remains a major cause of preventable
25 Modern Naval Mass Casualty Incidents With death and early hemostatic resuscitation is now a mainstay of
Implications for Future Distributed Maritime Operations treatment internationally. Recently, two randomized control trials
Matthew D. Tadlock, Jennifer Gurney, Michael S. Tripp, (RCTs) – PAMPer (Prehospital Air Medical Plasma) and COM­
Leopoldo C. Cancio, Michael J. Sise, Jesse Bandle, Miguel BAT (Control of Major Bleeding After Trauma), evaluating the
Cubano, Joseph Lee, Matthew Vasquez, José A. Acosta effect of pre­hospital use of plasma on mortality provided con­
J Trauma Acute Care Surg. 2021;91(2S Suppl 2):S46–S55. flicting results, raising important questions on the role of plasma
resuscitation in pre­hospital environment. Both PAMPer (n = 501
In the future, United States Navy Role 1 and Role 2 shipboard patients) and COMBAT (n = 144 patients) trials were pragmatic
medical departments will be caring for patients during Distributed RCTs that evaluated the effect of pre­hospital plasma transfusion
Maritime Operations in both contested and noncontested austere (two units) versus standard of care on 28/30 days mortality in
environments, likely for prolonged periods of time. This literature trauma patients who presented with clinical signs of hemorrhagic
review examines 25 modern naval mass casualty incidents over a shock (defined as hypotension or tachycardia). The PAMPer trial
40­year period representative of naval warfare, routine naval oper­ showed that plasma transfusion reduced 30­day mortality com­
ations, and ship­based health service support of air and land opera­ pared with standard of care (23% vs. 33%, 95% confidence in­
tions. Challenges, lessons learned, and injury patterns are identified terval –18.6; –1.0%; P = 0.03), while COMBAT trial showed no
to prepare afloat medical departments for the future fight. difference in 28­day survival. The post­hoc analyses of the two
trials have suggested that the benefit of pre­hospital plasma trans­
A Comparison of Efficacy, Efficiency, and Durability in fusion may be greater for patients who are coagulopathic, have
Novel Tourniquet Designs blunt injury, and have a transport time from the scene of injury to
Christopher Treager, Tyler Lopachin, Sally Mandichak, Bradley the hospital of > 20 minutes. In this review we evaluate strengths
Kinney, Megan Bohan, Michael Boboc, Christian Go, Emily and limitations of the two trials and their differences and similar­
Friedrich, Sean Stuart ities, which may explain the conflicting results, as well as provide
J Trauma Acute Care Surg. 2021;91(2S Suppl 2):S139–S145. directions for future trials to better define the target population
that would most benefit from pre­hospital plasma resuscitation.
Background: Exsanguination due to extremity hemorrhage is a Further, considering the logistical challenges of carrying any blood
major cause of preventable traumatic deaths. Extremity tourni­ components on an aircraft, cost/safety of plasma, and the scar­
quet use has been shown to be safe and improve survival. The city of universal blood group donors, there is a need for a health
purpose of this study was to compare the efficacy, efficiency, and economic evaluation of pre­hospital plasma transfusion in trauma
durability of the Generation 7 Combat Application Tourniquet patients, prior to this intervention becoming universal.
(CAT; North American Rescue, Greer, SC), the Tactical Mechan­
ical Tourniquet (TMT; Combat Medical Systems, Harrisburg,

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