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Schauer SG, Naylor JF, Ahmed YM, Maddry JK, April MD 20(3). 76 - 80 (Journal Article)

Background: The United States (US) military utilizes combat wound medication packs (CWMP) to provide analgesia and wound prophylaxis in casualties who are still able to fight. We compared characteristics of combat casualties receiving CWMP to those not receiving CWMP. We also describe the proportions of casualties with injury patterns consistent with Tactical Combat Casualty Care (TCCC) guideline indications for CWMP use who received this intervention. Methods: This is a secondary analysis of Department of a Defense Trauma Registry (DODTR) dataset of US military personnel from January 2007 to August 2016. We searched for all subjects with documented use of at least one medication from the CWMP (acetaminophen, meloxicam, moxifloxacin). Results: Within our dataset, 11,665 casualties were US military Servicemembers. Overall, <1% (84) of our study population received the CWMP. The median age and mechanism of injuries were similar between CWMP nonrecipients versus recipients. Median composite injury scores were higher for nonrecipients than recipients (6 versus 4, P < .001). Proportions of casualties with injury patterns meeting TCCC guideline CWMP indications who received this intervention were low: gunshot wound, <1% (14 of 1805), tourniquet applied, <1% (11 of 1912), major amputation, <1% (5 of 803), and open fracture, <1% (10 of 2425). Based on serious injuries by body region, we had similar findings for the thorax (<1%; 3 of 1122), abdomen (<1%; 1 of 736), and extremities (<1%; 11 of 2699). Conclusions: Subjects receiving the CWMP were less severely injured compared to those who did not receive this intervention. The CWMP had very infrequent use among those casualties with injury patterns meeting indications specified in the TCCC Guidelines for use of this intervention.

Fisher AD, Schwartz DS, Petersen CD, Meyer SE, Thielemann JN, Redman TT, Rush SC 20(3). 81 - 86 (Journal Article)

Background: Opioids can have adverse effects on casualties in hemorrhagic shock. In 2014, the Committee on Tactical Combat Casualty Care (CoTCCC) recommended the use of ketamine at the point of injury (POI). Despite these recommendations the adherence is moderate at best. Poor use may stem from a lack of access to use ketamine during training. The United States Special Operations Command (USSOCOM) is often in a unique position, they maintain narcotics for use during all training events and operations. The goal of this work is to demonstrate that ketamine is safe and effective in both training and operational environments. Methods: This was a retrospective, observational performance improvement project within United States Special Operations Command and Air Combat Command that included the US Army's 75th Ranger Regiment, 160th Special Operations Aviation Regiment, and US Air Force Pararescue. Descriptive statistics were used to calculate the doses per administration to include the interquartile range (IQR), standard deviation (SD) and the range of likely doses using a 95% confidence interval (CI). A Wilcoxon signed-rank test was used to compare the mean pre-ketamine pain scores to the mean post-ketamine on a 0-to-10 pain scale. Results: From July 2010 to October 2017, there was a total of 34 patients; all were male. A total of 22 (64.7%) received intravenous ketamine and 12 (35.3%) received intramuscular ketamine and 8 (23.5%) received intranasal ketamine. The mean number of ketamine doses via all routes administered to patients was 1.88 (SD 1.094) and the mean total dose of all ketamine administration was 90.29mg (95% CI, 70.09-110.49). The mean initial dose of all ketamine administration was 47.35mg (95% CI, 38.52-56.18). The median preketamine pain scale for casualties was noted to be 8.0 (IQR 3) and the median post-ketamine pain scale was 0.0 (IQR 3). Conclusion: Ketamine appears to be safe and effective for use during military training accidents. Military units should consider allowing their medics to carry and use as needed.

Shukal A, Perez C, Hoemann B, Keasal M 20(3). 67 - 70 (Journal Article)

Over the course of nearly 19 years of conflict, Tactical Combat Casualty Care (TCCC) guidelines and their implementation have evolved to incorporate the latest advances in trauma research, casualty care, and transport, playing a large role in generating the lowest incidence of preventable deaths in the history of modern warfare. During the conflicts in Afghanistan and Iraq, the adoption and implementation of TCCC principles by conventional forces have been extrapolated to have been responsible for saving the lives of more than 1,000 US Servicemembers. As the intensity and nature of the military conflicts in Afghanistan and Iraq change, and a growing potential for a near peer conflict rises, it remains important that the lessons of TCCC continue to be instilled in our formations in garrison, before deployment, and while in theater. This article reviews the use of TCCC principles by an assault helicopter battalion, in combination with a variety of other factors, in the successful management of a mass casualty event during Operation Freedom's Sentinel 2019 in Afghanistan.

Meadows RM, Monti JD, Umar MA, Van Arnem KA, Chin EJ, Mitchell CA, Love S 20(3). 71 - 75 (Journal Article)

Background: Ultrasound, due to recent advances in portability and versatility, has become a valuable clinical adjunct in austere, resource-limited settings and is well demonstrated to be an accurate/efficient means to detect pneumothorax. The purpose of this study was to evaluate the impact of hands-on ultrasound training on ultrasound-naive US Army combat medics' ability to detect sonographic findings of pneumothorax with portable ultrasound in a cadaver model. Methods: Ultrasound-naive US Army combat medics assigned to conventional military units were recruited from a single US Army installation and randomized to receive either didactic training only, or "blended" (didactic and hands-on) training on ultrasound detection of pneumothorax. Blinded participants were asked to perform a thoracic ultrasound exam on ventilated human cadaver models. Primary outcome measured was sensitivity and specificity of detecting sonographic findings of pneumothorax between cohorts. Results: Forty-three participants examined a total of 258 hemithoraces. The didactic-only cohort (n = 24) detected sonographic findings of pneumothorax with a sensitivity of 68% and specificity of 57%. The blended cohort (n = 19) detected sonographic findings of pneumothorax with an overall sensitivity of 91% and specificity of 80%. Detection sensitivities were similar between B-mode versus M-mode use. Conclusion: US Army combat medics can use portable U/S to detect sonographic findings of pneumothorax in a human cadaver model with high sensitivity after a brief, blended (didactic and hands-on) training intervention.

Hingtgen E, Wall PL, Buising CM 20(3). 52 - 61 (Journal Article)

Background: The OMNA Marine Tourniquet is a 5.1cm-wide, simple redirect buckle, hoop-and-loop secured, ratcheting tourniquet designed for storage and use in marine environments. This study evaluated self-application effectiveness and pressures. Methods: Triplicate secured, occlusion, and completion pressures were measured during 60 subjects pulling down or up thigh applications and nondominant, single-handed arm applications. Arm pressure measurements required circumferences ≥30cm. Results: Thirty-one subjects had arm circumferences ≥30cm. All 540 applications were effective; 376 of 453 applications had known secured pressures >150mmHg (89 of 93 arm). Thigh down versus up pulling directions were not different (secured, occlusion, and completion pressures and ladder tooth advances). Occlusion pressures were 348mmHg (275-521mmHg) for combined thighs and 285mmHg (211-372mmHg) for arms. Completion pressures were 414mmHg (320-588mmHg) for combined thighs and 344mmHg (261-404mmHg) for arms. Correlations between secured pressures and occlusion ladder tooth advances (clicks) were r2 = 0.44 for combined thighs and 0.68 for arms. Correlations between occlusion pressures and occlusion clicks were poor (r2 = 0.24, P < .0001 for combined thighs and r2 = 0.027, P = .38 for arms). Conclusions: The OMNA Marine Tourniquet can be self-applied effectively, including one-handed applications. Occlusion and completion pressures are similar to reported 3.8cm-wide Ratcheting Medical Tourniquet pressures.

Schauer SG, Naylor, JF, Beaumont, DM, April MD, Tanaka K, Baldwin D, Maddry JK, Becker TE, De Lorenzo RA 20(3). 62 - 66 (Journal Article)

Introduction: Airway compromise is the second leading cause of potentially survivable death on the battlefield. Studies show that airway management is a challenge in prehospital combat care with high error and missed opportunity rates. Lacking is user information on the perceived reasons for the challenges. The US military uses several performance improvement and field feedback systems to solicit feedback regarding deployed experiences. We seek to review feedback and after-action reviews (AARs) from end-users with specific regard to airway challenges noted. Methods: We queried the Center for Army Lessons Learned (CALL), the Army Medical Department Lessons Learned (AMEDDLL), and the Joint Lessons Learned Information System (JLLIS).Our queries comprised a series of search terms with a focus on airway management. Three military emergency medicine expert reviewers performed the primary analysis for lessons learned specific to deployment and predeployment training lessons learned. Upon narrowing the scope of entries to those relevant to deployment and predeployment training, a panel of eight experts performed reviews. The varied nature of the sources lent itself to an unstructured qualitative approach with results tabulated into thematic categories. Results: Our initial search yielded 611 nonduplicate entries. The primary reviewers then analyzed these entries to determine relevance to the project-this resulted in 70 deployment- based lessons learned and four training-based lessons learned. The panel of eight experts then reviewed the 74 lessons learned. We categorized 37 AARs as equipment challenges/malfunctions, 28 as training/education challenges, and 9 as other. Several lessons learned specifically stated that units failed to prioritize medic training; multiple comments suggested that units should consider sending their medics to civilian training centers. Other comments highlighted equipment shortages and equipment malfunctions specific to certain mission types (e.g., pediatric casualties, extreme weather). Conclusions: In this review of military lessons learned systems, most of the feedback referenced equipment malfunctions and gaps in initial and maintenance training.This review of AARs provides guidance for targeted research efforts based the needs of the end-users.

Drew B, Auten JD, Cap AP, Deaton TG, Donham B, Dorlac WC, DuBose JJ, Fisher AD, Ginn AJ, Hancock J, Holcomb JB, Knight J, Koerner AK, Littlejohn LF, Martin MJ, Morey JK, Morrison J, Schreiber MA, Spinella PC, Walrath B, Butler FK 20(3). 36 - 43 (Journal Article)

The literature continues to provide strong support for the early use of tranexamic acid (TXA) in severely injured trauma patients. Questions persist, however, regarding the optimal medical and tactical/logistical use, timing, and dose of this medication, both from the published TXA literature and from the TCCC user community. The use of TXA has been explored outside of trauma, new dosing strategies have been pursued, and expansion of retrospective use data has grown as well. These questions emphasize the need for a reexamination of TXA by the CoTCCC. The most significant updates to the TCCC Guidelines are (i) including significant traumatic brain injury (TBI) as an indication for TXA, (ii) changing the dosing protocol to a single 2g IV/IO administration, and (iii) recommending TXA administration via slow IV/IO push.

Kragh JF, Aden JK, Dubick MA 20(3). 44 - 51 (Journal Article)

Background: Given little data to assess guidelines, we sought a way to exchange one type of intervention, field tourniquet use, for another, use of a pressure dressing. The study purpose was to test performance of controlling simulated bleeding with a stepwise procedure of tourniquet conversion. Methods: An experiment was designed to assess 15 tests of a caregiver making tourniquet-dressing conversions. Tests were divided into trials: tourniquet use and its conversion. In laboratory conditions, the tourniquet trial was care under gunfire; then, the conversion trial was emergency healthcare. A HapMed Leg Tourniquet Trainer simulated a limb amputation. An investigator provided healthcare. Results: Mean (± standard deviation [SD]) test time and blood loss were 9 ± 3.6 minutes and 334 ± 353.9mL, respectively. The first test took 17 minutes. By test number, times decreased; the last six took ≤7 minutes. All tourniquet trials controlled bleeding. Mean (±SD) tourniquet pressure and blood loss were 222 ± 18.0mmHg and 146 ± 40.9mL, respectively. Bleeding remained uncontrolled in one conversion. Initial attempts to wrap a dressing were effective in 73% of tries (n = 11 of 15). Four of 15 wrap attempts (27%) were repeated to troubleshoot bleeding recurrence, and the first three tests required a repetition. Mean (±SD) dressing pressures and blood losses were 141 ± 17.6mmHg and 188 ± 327.4mL, respectively. Unsatisfactory conversion trials had a dressing pressure <137mmHg. Dressings and wraps hid the wound to impair assessment of bleeding. Conclusions: In testing a method of converting a limb tourniquet to a pressure dressing, the caregiver performed faster with experience accrual. The tourniquet results were uniformly good, but conversion results were worse and more varied. Simulating conversion was disappointing on a manikin and indicated that its redesign might be needed to suit this method. The procedural method constituted a start for further development.

Nicholson J, Searor JN, Lane AD 20(3). 117 - 119 (Editorial)

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.

Bennett BL, Giesbrect G, Zafren K, Christensen R, Littlejohn LF, Drew B, Cap AP, Miles EA, Butler FK, Holcomb JB, Shackelford SA 20(3). 21 - 35 (Journal Article)

As an outcome of combat injury and hemorrhagic shock, trauma-induced hypothermia (TIH) and the associated coagulopathy and acidosis result in significantly increased risk for death. In an effort to manage TIH, the Hypothermia Prevention and Management Kit™ (HPMK) was implemented in 2006 for battlefield casualties. Recent feedback from operational forces indicates that limitations exist in the HPMK to maintain thermal balance in cold environments, due to the lack of insulation. Consequently, based on lessons learned, some US Special Operations Forces are now upgrading the HPMK after short-term use (60 minutes) by adding insulation around the casualty during training in cold environments. Furthermore, new research indicates that the current HPMK, although better than no hypothermia protection, was ranked last in objective and subjective measures in volunteers when compared with commercial and user-assembled external warming enclosure systems. On the basis of these observations and research findings, the Committee on Tactical Combat Casualty Care decided to review the hypothermia prevention and management guidelines in 2018 and to update them on the basis of these facts and that no update has occurred in 14 years. Recommendations are made for minimal costs, low cube and weight solutions to create an insulated HPMK, or when the HPMK is not readily available, to create an improvised hypothermia (insulated) enclosure system.

Hoggarth A, Grist M, Murch T 20(2). 154 - 155 (Journal Article)

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.

Glavacevic L, Karlovic K, Gallagher E 20(2). 144 - 147 (Journal Article)

Nongovernment organizations (NGOs) have become increasingly common in conflict zones throughout the world. They provide services that have been the responsibility of understaffed, undersupplied, and undertrained local nations and communities. However, these organizations face many difficulties. They are walking a thin line between militaries, governments, and local politics. They must find ways to stay supplied and staffed. The research presented in this article focuses on three NGOs and the impact they are making throughout the world. By understanding the role these organizations play in providing medical relief to conflict zones without the help of government agencies, one can see the importance of their work and the struggles they face.

Hampton K, Van Humbeeck L 20(2). 148 (Journal Article)

Crecelius EM, Burnett MW 20(2). 136 - 138 (Journal Article)

Measles is a significant concern with approximately 10 million people infected annually causing over 100,000 deaths worldwide. In the US before use of the measles vaccine, there were estimated to be 3 to 4 million people infected with measles annually, causing 400 to 500 deaths. Complications of measles include otitis media, diarrhea, pneumonia, and acute encephalitis. Measles is a leading cause of blindness in the developing world, especially in those who are vitamin A deficient. Malnourished children with measles are also at higher risk of developing noma (or cancrum oris), a rapidly progressive gangrenous infection of the mouth and face. Most deaths due to measles are caused by pneumonia, diarrhea, or neurological complications in young children, severely malnourished or immunocompromised individuals, and pregnant women. A rare sequela of measles is subacute sclerosing panencephalitis.

Knapik JJ, Hoedebecke BL, Mitchener TA 20(2). 139 - 143 (Journal Article)

This is the first of a two-part series on the history and effectiveness of mouthguards (MGs) for orofacial injury protection. Military studies have shown that approximately 60% of orofacial injuries are associated with military training activities and 20% to 30% with sports. MGs are hypothesized to reduce orofacial injuries by separating the upper and lower dentation, preventing tooth fractures, redistributing and absorbing the force of direct blows to the mouth, and separating teeth from soft tissue, preventing lacerations and bruises. In 1975, CPT Leonard Barber was the first to advocate MGs for military sports activities. In 1998, Army health promotion campaigns promoted MG education and fabrication. A US Army basic training study in 2000-2003 showed that more MG use could reduce orofacial injuries and the Army Training and Doctrine Command subsequently required that basic trainees be issued and use MGs. Army Regulation 600-63 currently directs commanders to enforce MG use during training and sports activities that could involve orofacial injuries. In the civilian sector, MGs were first used by boxers and then were required for football. MGs are currently required nationally for high school and college football, field hockey, ice hockey, and lacrosse, and are recommended for 29 sport and exercise activities.

Perry EB, Powell EB, Discepolo DR, Francis JM, Liang SY 20(2). 127 - 131 (Journal Article)

Working canines are frequently exposed to hazardous environments with a high potential for contamination. Environmental contamination may occur in many ways. Contamination may be chemical, biological, radiological, or nuclear. Examples may include a pipeline rupture following an earthquake, microbiological contamination of floodwaters, or exposure to toxic industrial chemical such as hydrogen chloride, ammonia, or toluene. Evidence to support effective methods for decontamination of equipment commonly used by working canines is lacking. Recent work has identified decontamination protocols for working canines, but little data are available to guide the decontamination of equipment used during tactical operations. The objective of our work was to investigate the effects of cleanser, cleaning method, and material type on contaminant reduction for tactical canine equipment materials using an oil-based contaminant as a surrogate for toxic industrial chemical exposure. A contaminant was applied, and effectiveness was represented as either success (≥ 50% contaminant reduction) or failure (< 50% contaminant reduction). A two-phase study was used to investigate cleanser, method of cleaning, and material types for effective contaminant reduction. In phase 1, Simple Green® cleanser had a higher frequency (P = .0075) of failure, but method and material did not affect contamination reduction (P > .05). In phase 2, Dawn® (P = .0004) and Johnson's® (P = .0414) successfully reduced contamination. High-pressure cleaning (HPC) resulted in successful decontamination (P < .0001). These novel data demonstrate potential techniques for reduction of contaminants on tactical canine equipment.

Crawford C, Deuster PA 20(2). 132 - 135 (Journal Article)

Dietary supplements promoted for brain health and enhanced cognitive performance are becoming increasingly popular. Special Operations Forces (SOF) is likely a prime target for this market as they strive to continually optimize and then sustain their high level of performance at all times. When a dietary supplement hits the market, it is considered safe until it is proven otherwise; yet the majority have not been analyzed for quality or tested for safety. The authors describe issues related to products marketed for brain health and cognitive enhancement and focus on products brought to our attention by the operational communities. The overwhelming majority of product labels were found to be misbranded and some were found to contain prohibited ingredients and drugs. The problematic ingredients in these products are introduced. The Operation Supplement Safety scorecard algorithm is demonstrated as a tool to quickly screen a product for potential safety; it can be used in real-time when considering the use of any dietary supplement product. These resources are available to help SOF medical assets evaluate whether a product's claims may be deceiving and potentially harmful to the health or career of Operators.

Martinson J, Park H, Butler FK, Hammesfahr R, DuBose JJ, Scalea TM 20(2). 116 - 122 (Journal Article)

The American College of Surgeons' "Stop the Bleed" (STB) campaign emphasizes how to apply the Combat Application Tourniquet (CAT), a device adopted by the military to control extremity hemorrhage. However, multiple commercially available alternatives to the CAT exist, and it would be helpful for instructors to be knowledgeable about how these other models compare. A PubMed search from January 2012 to January 2020 cross-referenced with a Google search for "tourniquet" was performed for commercially available tourniquets that had been trialed against the CAT. Windlass-type models included the Special Operations Forces Tactical Tourniquet (SOFT-T), the SOFT-T Wide (SOFFT-W), the SAM-XT tourniquet, the Military Emergency Tourniquet (MET), and the Tactical Medical Tourniquet (TMT). Elastic-type tourniquets included were the Stretch, Wrap, And Tuck Tourniquet (SWAT-T), the Israeli Silicone Tourniquet (IST), and the Rapid Activation Tourniquet System (RATS). Ratchet-type tourniquets included were the Ratcheting Medical Tourniquet (RMT) and TX2/TX3 tourniquets, and pneumatic-type tourniquets were the Emergency and Military Tourniquet (EMT) and Tactical Pneumatic Tourniquet (TPT). This review aims to describe the literature surrounding these models so that instructors can help laypeople make more informed purchases, stop the bleed, and save a life.

Lewis C, Nilan M, Srivilasa C, Knight RM, Shevchik J, Bowen B, Able T, Kreishman P 20(2). 123 - 126 (Journal Article)

We present the case of a severely injured Special Operations Servicemember whose care was remarkable for three unique interventions: the first use of a walking blood bank performed at the point of injury, prolonged permissive hypotension, and intermittent resuscitative endovascular balloon occlusion of the aorta (REBOA).