America's adversaries will contest US military superiority in the domains of land, sea, air, space, and cyberspace. Fundamentally, these foes seek to disrupt the dominance of American fighting forces through anti-access and area denial (A2AD) systems, such as cyber exploitation, electromagnetic jamming, air defense networks, and hypersonic capabilities. According to Training and Doctrine Command (TRADOC) Pamphlet 525- 3-1, these A2AD capabilities create multiple layers of stand-off that inhibit the US ability to focus combat power and achieve strategic objectives in a contested, increasingly lethal, inherently complex, and challenging operational environment.1 The Department of Defense (DoD) plans to mitigate this shift in enemy strategy through the adoption of multidomain operations (MDO).1 MDO is defined as operations that converge capabilities to overcome an adversary's strengths across various domains by imposing simultaneous dilemmas that achieve operational and tactical objectives.1 Within this MDO construct, medical treatment expectations must shift accordingly as the ability to rapidly treat and evacuate patients may be constrained by enemy action. Thus, the notion of prolonged field care (PFC) may be a necessity on the future battlefield. As Special Operations Forces (SOF) continue to refine what PFC entails, it is imperative that an understanding of the incidence and type of diseases that require medical evacuation to higher levels of care be thoughtfully estimated. Armed with an understanding of the anticipated epidemiology, effective prioritization of training requirements and equipment acquisition is possible in a manner that is complementary to the overall success of the assigned mission. Furthermore, this prior planning mitigates risk, as the limitations of money and time impose significant opportunity costs in the short run should the disproportionate mix of disease states be pursued, which in turn, avoids jeopardizing Soldiers' lives over the long term.
Thompson P, Hudson AJ, Convertino VA, Bjerkvig C, Eliassen HS, Eastridge BJ, Irvine-Smith T, Braverman MA, Hellander S, Jenkins DH, Rappold JF, Gurney JM, Glassberg E, Cap AP, Aussett S, Apelseth TO, Williams S, Ward KR, Shackelford SA, Stroberg P, Vikeness BH, Pepe PE, Winckler CJ, Woolley T, Enbuske S, De Pasquale M, Boffard KD, Austlid I, Fosse TK, Asbjornsen H, Spinella PC, Strandenes G. 20(3). 97 - 102. (Editorial)
Based on limited published evidence, physiological principles, clinical experience, and expertise, the author group has developed a consensus statement on the potential for iatrogenic harm with rapid sequence induction (RSI) intubation and positive-pressure ventilation (PPV) on patients in hemorrhagic shock. "In hemorrhagic shock, or any low flow (central hypovolemic) state, it should be noted that RSI and PPV are likely to cause iatrogenic harm by decreasing cardiac output." The use of RSI and PPV leads to an increased burden of shock due to a decreased cardiac output (CO)2 which is one of the primary determinants of oxygen delivery (DO2). The diminishing DO2 creates a state of systemic hypoxia, the severity of which will determine the magnitude of the shock (shock dose) and a growing deficit of oxygen, referred to as oxygen debt. Rapid accumulation of critical levels of oxygen debt results in coagulopathy and organ dysfunction and failure. Spontaneous respiration induced negative intrathoracic pressure (ITP) provides the pressure differential driving venous return. PPV subsequently increases ITP and thus right atrial pressure. The loss in pressure differential directly decreases CO and DO2 with a resultant increase in systemic hypoxia. If RSI and PPV are deemed necessary, prior or parallel resuscitation with blood products is required to mitigate post intervention reduction of DO2 and the potential for inducing cardiac arrest in the critically shocked patient.
Parker PJ. 20(1). 40 - 42. (Editorial)
Keenan S. 18(1). 139 - 140. (Editorial)
Vasios WN. 16(1). 62 - 65. (Editorial)
Clark JR. 13(3). 99 - 100. (Editorial)
Pennardt A. 10(3). 49 - 49. (Editorial)