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of traumatic injuries from PubMed, Web of Science, and CINAHL. index was used to define hypothermia within the predetermined
Manuscripts were reviewed to select for English language studies. population based on mortality risk. A multivariable regression
Hypocalcemia was defined as i-Ca <1.2mmol/L. Results: Using model was used to identify associations. Results: There were 23,243
PRISMA guidelines, we reviewed 300 studies, 7 of which met our encounters that met the inclusion criteria for this study with pa-
inclusion criteria. Five papers showed an association between hy- tients having received prehospital care and documentation of at
pocalcemia and mortality. Conclusions: In adult trauma patients, least one emergency department temperature. An optimal thresh-
there has been an association seen between hypocalcemia, mor- old of 36.2°C was found to predict mortality; 3,159 casualties had
tality, and the need for increased blood product transfusions. It is temperatures below this threshold (14%). Survival to discharge was
possible we are now seeing an association between low calcium lower among casualties with hypothermia (91% versus 98%). Hy-
levels prior to blood product administration and an increased risk pothermic casualties were less likely to undergo blanket application
for mortality and need for transfusion. Hypocalcemia may serve (38% versus 40%). However, they had higher proportions with Hy-
as a biomarker to show these needs. pothermia Prevention and Management Kit application (11% ver-
sus 7%) and radiant warming (2% versus 1%). On multivariable
Therefore, hypocalcemia could potentially be used as an indepen- regression modeling, none of the hypothermia interventions were
dent predictor for multiple transfusions such that ionized calcium associated with a decreased likelihood of hypothermia. Non-hy-
measurements could be used predictively, allowing faster adminis- pothermia interventions associated with hypothermia included
tration of blood products
prehospital intubation (OR 1.57, 95% CI 1.45–1.69) and blood
Management of hypothermia in Tactical Combat product administration. Conclusions: Hypothermia, including a
Casualty Care: TCCC Guideline Proposed Change 20-01 single recorded low temperature in the patient care record, was as-
(June 2020) sociated with worse outcomes in this combat trauma population.
Prehospital intubation was most strongly associated with develop-
BL Bennett, PhD; Gordon Giesbrecht, PhD; Ken Zafren, MD; ing hypothermia. Prehospital warming interventions were not asso-
Ryan Christensen; Lanny Littlejohn, MD; Brendon Drew, DO; ciated with a reduction in hypothermia risk. Our dataset suggests
Andrew Cap, MD, PhD; Ethan Miles, MD; Frank Butler, MD; that current methods for prehospital warming are inadequate.
John B Holcomb, MD; Stacy Shackelford, MD
J Spec Oper Med. 20(3):21–35. Epidemiology, patterns of care and outcomes of
traumatic brain injury in deployed military settings:
As an outcome of combat injury and hemorrhagic shock, trau- implications for future military operations
ma-induced hypothermia (TIH) and the associated coagulopathy
and acidosis result in significantly increased risk for death. In an Bradley A Dengler, MD, Yll Agimi, PhD, Katharine Stout, DPT,
effort to manage TIH, the Hypothermia Prevention and Manage- Krista L Caudle, PhD, Kenneth C Curley, MD, Sarah Sanjakdar,
ment Kit™ (HPMK) was implemented in 2006 for battlefield ca- PhD, Malena Rone, PhD, Brian Dacanay, MS, Jonathan C Fru-
sualties. Recent feedback from operational forces indicates that endt, MD, James B Phillips, PhD, Ana-Claire L Meyer, MD, MSHS
limitations exist in the HPMK to maintain thermal balance in cold J Trauma Acute Care Surg. 2022;93(2):220–228.
environments, due to the lack of insulation. Consequently, based Background: Traumatic brain injury (TBI) is prevalent and highly
on lessons learned, some US Special Operations Forces are now up-
grading the HPMK after short-term use (60 minutes) by adding in- morbid among Service Members. A better understanding of TBI
epidemiology, outcomes, and care patterns in deployed settings
sulation around the casualty during training in cold environments.
Furthermore, new research indicates that the current HPMK, al- could inform potential approaches to improve TBI diagnosis and
management. Methods: A retrospective cohort analysis of Service
though better than no hypothermia protection, was ranked last in
objective and subjective measures in volunteers when compared Members Defense Health Agency TCCC All Service Members
Course. Members who sustained a TBI in deployed settings be-
with commercial and user-assembled external warming enclosure
systems. On the basis of these observations and research findings, tween 2001 and 2018 was conducted. Among individuals hospi-
talized with TBI, we compared the demographic characteristics,
the Committee on Tactical Combat Casualty Care decided to re-
view the hypothermia prevention and management guidelines in mechanism of injury, injury type, and severity between combat
and noncombat injuries. We compared diagnostic tests and proce-
2018 and to update them on the basis of these facts and that no
update has occurred in 14 years. Recommendations are made for dures, evacuation patterns, return to duty rates and days in care
between individuals with concussion and those with severe TBI.
minimal costs, low cube and weight solutions to create an insu-
lated HPMK, or when the HPMK is not readily available, to create Results: There were 46,309 Servicemembers with TBI and 9,412
who were hospitalized; of those hospitalized, 55% (4,343) had
an improvised hypothermia (insulated) enclosure system.
isolated concussion and 9% (796) had severe TBI, of whom 17%
Hypothermia in the combat trauma population (132/796) had multiple injuries. Overall mortality was 2% and
ranged from 0.1% for isolated concussion to 18% for severe TBI.
Steven G. Schauer, Michael D. April, Andrew D. Fisher, Wells L. The vast majority of TBI were evacuated by rotary wing to role 3
Weymouth, Joseph K. Maddry, Kevin R. Gillespie, Jose Salinas and or higher, including those with isolated concussion. As compared
Andrew P. Cap
with severe TBI, individuals with isolated concussion had fewer
Prehosp Emerg Care. 2022 Sep 19;1–7. diagnostic or surgical procedures performed. Only 6%of Service-
Background: The MARCH (Massive hemorrhage, Airway, Respi- members with severe TBI were able to return to duty as compared
rations, Circulation, and Hypothermia/Head injuries) algorithm with 54% of those with isolated concussion. Traumatic brain in-
taught to military medics includes interventions to prevent hypo- jury resulted in 123,677 lost duty days; individuals with isolated
thermia. As possible sequelae from major trauma, hypothermia is concussion spent a median of 2 days in care and those with severe
associated with coagulopathy and lower survival. This paper sought TBI spent a median of 17 days in care and a median of 6 days
to define hypothermia within our combat trauma population using in the intensive care unit. Conclusion: While most TBI in the de-
an outcomes-based method, and determine clinical variables asso- ployed setting are mild, TBI is frequently associated with hospital-
ciated with hypothermia. Methods: This is a secondary analysis ization and multiple injuries. Overtriage of mild TBI is common.
of a previously described dataset from the Department of Defense Improved TBI capabilities applicable to forward settings will be
Trauma Registry focused on casualties who received prehospital critical to the success of future multidomain operations with lim-
care. A receiver operating curve was constructed and Youden’s itations in air superiority.

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