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Joint Trauma System Clinical Practice Guideline: Acute Coronary Syndrome (ACS). 14 May 2021

21(3). 11 - 20 (Journal Article)

Deployed medical providers at all roles of care must be prepared to recognize and manage acute coronary syndrome (ACS). Under optimal conditions, treatment is initiated with medical therapy and may be followed by prompt coronary angiography and revascularization. Emergent percutaneous coronary intervention (PCI) is not available in most deployed locations, however, and the time for such intervention is often dependent on long-range evacuation. This CPG provides guidance on best management for ACS patients in the deployed and resource-constrained environment.

Autopsy-Determined Atherosclerosis in Elite US Military Special Operations Forces

Kotwal RS, Mazuchowski EL, Howard JT, Hanak JC, Harcke HT, Gurney JM, Shackelford SA 21(2). 19 - 24 (Journal Article)

Background: Autopsy studies of trauma fatalities have provided evidence for the pervasiveness of atherosclerosis in young and middle-aged adults. The objective of this study was to determine the prevalence of atherosclerosis in elite US military forces. Methods: We conducted a retrospective study of all US Special Operations Command (USSOCOM) fatalities from 2001 to 2020 who died from battle injuries. Autopsies were evaluated from Afghanistan- and Iraq-centric combat operations for evidence of coronary and/or aortic atherosclerosis and categorized as minimal (fatty streaking only), moderate (10-49% narrowing of ≥1 vessel), and severe (≥50% narrowing of ≥1 vessel). Prevalence of atherosclerosis was determined for the total population and by subgroup characteristics of age, sex, race/ethnicity, combat operation, service command, occupation, rank, cause of death, manner of death, and body mass index (BMI). Results: From the total of 388 USSOCOM battle injury fatalities, 356 were included in the analysis. The mean age was 31 years (range, 19-57 years), and 98.6% were male. The overall prevalence of coronary and/or aortic atherosclerosis was 17.4%. The prevalence of coronary atherosclerosis alone was 13.8%. Coronary atherosclerosis was categorized as minimal in 1.1%, moderate in 7.6%, and severe in 5.1%. Of those with atherosclerosis, 24.2% were <30 years old, 88.7% were from enlisted ranks, and 95.2% had combatant occupations. When BMI could be calculated, 73.5% of fatalities with atherosclerosis had a BMI ≥25. Conclusions: Autopsy-determined atherosclerosis is prevalent in elite US military Special Operations Forces despite young age and positive lifestyle benefits of service in an elite military unit.

23.4% Hypertonic Saline: A Tactical Option for the Management of Severe Traumatic Brain Injury With Impending or Ongoing Herniation

DeSoucy ES, Cacic K, Staak BP, Petersen CD, van Wyck D, Rajajee V, Dorsch J, Rush SC 21(2). 25 - 28 (Journal Article)

There are limited options available to the combat medic for management of traumatic brain injury (TBI) with impending or ongoing herniation. Current pararescue and Tactical Combat Casualty Care (TCCC) guidelines prescribe a bolus of 3% or 5% hypertonic saline. However, this fluid bears a tactical burden of weight (~570g) and pack volume (~500cm3). Thus, 23.4% hypertonic saline is an attractive option, because it has a lighter weight (80g) and pack volume (55cm3), and it provides a similar osmotic load per dose. Current literature supports the use of 23.4% hypertonic saline in the management of acute TBI, and evidence indicates that it is safe to administer via peripheral and intraosseous cannulas. Current combat medic TBI treatment algorithms should be updated to include the use of 23.4% hypertonic saline as an alternative to 3% and 5% solutions, given its effectiveness and tactical advantages.

Operation Blood Rain: The Effect of Airdrop on Fresh Whole Blood

Tong RL, Bohlke CW, Clemente Fuentes RW, Moncada M, Schloe AD, Ashley RL 21(2). 29 - 33 (Journal Article)

Background: Administration of fresh whole blood (FWB) is a life-saving treatment that prolongs life until definitive surgical intervention can be performed; however, collecting FWB is a time-consuming and resource-intensive process. Furthermore, it may be difficult to collect sufficient FWB to treat critically wounded patients or multiple-hemorrhaging casualties. This study describes the effect of airdrop on FWB and explores the possibility of using airdrop to deliver FWB to combat medics treating casualties in the prehospital setting when FDA-approved, cold-stored blood products are not readily available and timely casualty evacuation (CASEVAC) is not feasible. Methods: Four units of FWB were collected from volunteer donors and loaded into a blood cooler that was dropped from a fixed-wing aircraft under a standard airdrop training bundle (SATB) parachute. A control group of 4 units of FWB was stored in a blood cooler that was not dropped. Baseline and postintervention laboratory samples were measured in both airdropped and control units, including full blood counts, prothrombin time/partial thromboplastin time/international normalized ratio (PT/PTT/INR), pH, lactate, potassium, indirect bilirubin, glucose, fibrinogen, lactate dehydrogenase, and peripheral blood smears. Results: The blood cooler, cooling bags, and all 4 FWB units did not sustain any damage from the airdrop. There was no evidence of hemolysis. All airdropped blood met parameters for transfusion per the Whole Blood Transfusion Clinical Practice Guideline of the Joint Trauma System (JTS). Conclusions: Airdrop of FWB in a blood cooler with a SATB parachute may be a viable way of delivering blood products to combat medics treating hemorrhaging patients in the prehospital setting, although further research is needed to fully validate the safety of this method of FWB delivery.

Unconventionally Acquired Brain Injury: Guidance and Instruction About an Emerging Challenge to Warfighter Brain Health

Biggs AT, Henry SM, Johnston SL, Whittaker DR, Littlejohn LF 21(2). 43 - 48 (Journal Article)

Special Operations Forces have made brain health a medical priority in recent years, and new guidance identified a new challenge-unconventionally acquired brain injury (UBI). Although this emerging condition is described as a cluster of neurosensory and cognitive symptoms with unknown etiology/ origin, there remain critical questions about how this diagnosis differs from other brain injuries. More importantly, there are limited recommendations about how medical personnel should approach the problem. The current discussion will provide context and information about UBI based on higher guidance and will also review the scant literature to provide context. Foremost, UBI can be distinguished from traumatic brain injury (TBI) largely due to an unknown point of injury. The described symptoms otherwise appear to be largely the same as TBI. Likewise, the recommended course of treatment is to follow the Clinical Practice Guidelines for mild TBI/TBI even if the injury is an actual or suspected UBI. Personnel must be careful to avoid entering sensitive information into the medical record, which may be particularly challenging if identifying the cause involves classified information about an unconventional weapon. Finally, we briefly discuss the literature about several suspected incidents fitting UBI diagnostic criteria, and we conclude with five primary takeaways for medical personnel to follow.

An Analysis of Prehospital Trauma Registry After-Action Reviews in Afghanistan

Carius BM, Dodge PM, Fisher AD, Loos PE, Thompson D, Schauer SG 21(2). 49 - 53 (Journal Article)

Background: After-action reviews (AARs) in the Prehospital Trauma Registry (PHTR) enable performance improvements and provide commanders feedback on care delivered at Role 1. No published data exist exploring overall trends of end-user performance-improvement feedback. Methods: We performed an expert panel review of AARs within the PHTR in Afghanistan from January 2013 to September 2014. When possible, we categorized our findings and selected relevant medical provider comments. Results: Of 737 registered patient encounters found, 592 (80%) had AAR documentation. Most AAR patients were male (98%, n = 578), injured by explosion (48%, n = 283), and categorized for urgent evacuation (64%, n = 377). Nearly two thirds of AARs stated areas needing improvement (64%, n = 376), while the remainder left the improvement section blank (23%, n = 139) or specified no improvements (13%, n = 76). The most frequently cited areas for improvement were medical knowledge (23%, n = 136), evacuation coordination (19%, n = 115), and first responder training (16%, n = 95). Conclusions: Our expert panel reviewed AARs within the PHTR and found substantial numbers of AARs without improvements recommended, which limits quality improvement capabilities. Our analysis supports previous calls for better documentation of medical care in the prehospital combat setting.

Project Reach: A Pilot Cross-Sectional Study of the Telemedical Capabilities of Special Operations Medical Personnel

Carlton DM, Lowery D, Woodard C, Lugo-Robles R, Charny G 21(2). 54 - 60 (Journal Article)

Background: While the US military has relied on the "Golden Hour" for casualty evacuation in Iraq and Afghanistan during most of the last two decades, Special Operations Forces (SOF) personnel have found themselves operating further outside of this established medical infrastructure. This has required prolonged casualty care beyond doctrinal timelines. Telemedicine is increasingly used by medical personnel to bridge this gap, augmenting the local staff with the expertise of a distant consultant. This pilot study was launched to establish a baseline of current SOF telemedical capabilities. Methods: This is a cross-sectional study of a 292 Department of Defense (DoD) SOF medical personnel via an online questionnaire during the period of October 2018-May 2019. Results: Approximately 16.1% of the 292 respondents stated they received telemedicine equipment, 51.1% of respondents who received telemedicine equipment reported also receiving training on their equipment. Overall, 40.6% of respondents were "actively looking to add telemedicine to their practice," with prolonged field care as the primary intended use. Ideal characteristics of telemedicine equipment were described as a device weighing 6 lb or less, with real-time video and ultrasound transmission capabilities. Discussion: The data demonstrated a gap between provider demand for telemedicine capabilities and their comfort to employ these capabilities downrange. Conclusions: This study suggests a need to increase the self-reported telemedicine competency of deployed local providers. Authors believe that this is best accomplished through incorporation of early integration of teleconsulting systems into mission rehearsals and unit exercises. Further study should be considered to investigate the efficacy of ongoing acquisition and training programs, along with how telemedicine is being incorporated in the unit during the predeployment training period.

Targeted Intervention Improves Symptoms and Impairments in Patients With Mild Traumatic Brain Injury With Chronic Symptom: A Prospective, Multiple Interventional Research Trial

Eagle SR, Kontos AP, Collins MW, Mucha A, Holland CL, Edelman K, Benso S, Schneider W, Soose R, Okonkwo DO 21(2). 61 - 66 (Journal Article)

Background: Mild traumatic brain injury (mTBI) and its potential long-term consequences is a primary concern for the US military. The purpose of the study is to evaluate if participants improved in anxiety/mood symptoms, sleep quality, and vestibular/ocular symptoms following a 6-month active intervention, and to explore the effect of targeted treatment for those with specific symptoms/impairments (e.g., psychological, sleep, ocular, vestibular). Materials and Methods: A multidisciplinary clinical team adjudicated participants (n=72, 35.8±8.6 years old, 19% female) to have one of the following primary clinical trajectories: psychological (PSYCH; n=34), sleep (SLEEP; n=25) and vestibular/ocular (VESTIB/OCULAR; n=18). Participants returned for follow-up assessment 6 months later. Assessments included the Post-Concussion Symptom Scale [PCSS], Generalized Anxiety Disorder-7 [GAD-7], Pittsburgh Sleep Quality Index [PSQI], and Dizziness Handicap Inventory [DHI]. Change in concussion symptoms and primary outcome for the given trajectory (i.e., PSYCH=GAD-7, SLEEP=PSQI, VESTIB/OCULAR=DHI) was assessed. Results: Following the 6-month intervention, participants reduced PCSS Score (-14.5±2.4; p<.001; η2=0.34), GAD-7 (-3.1±0.5; p<.001; η2=0.34), PSQI (-2.7±0.5; p<.001; η2=0.34) and DHI (-9.2±2.0; p<.001; η2=0.23). PSYCH (n=34) reduced PCSS score (-17.9±3.6; p<.001; η2=0.45) and GAD-7 (-3.1±0.7; p<.001; η2=0.38). SLEEP (n=25) reduced PCSS score (-8.8±4.4; p=.06; η2=0.15) and PSQI (-3.6±0.9; p<.001; η2=0.45) scores. VESTIB/OCULAR (n=18) reduced PCSS score (-16.7±4.8; p=.03; η2=0.45), and DHI (-15.7±5.5; p=.012; η2=0.35). Conclusions: Large effects were observed for concussion, anxiety, sleep, and dizziness symptom reduction over 6-month treatment. Each primary outcome demonstrated a larger treatment effect for the given trajectory than the overall sample, indicating that targeted treatment can reduce symptom burden in patients with mTBI with chronic symptoms.

Prevalence of Low Back and Cervical Back Pain in Military Helicopter Crews: An Underestimated Italian Problem

Marchesini M, Ippolito C, Ambrosini L, Bignami EG, Fasani M, Abbenante D 21(2). 67 - 71 (Journal Article)

Background: Studies have highlighted the incidence and prevalence of chronic pain, which is an epidemic problem in all career sectors, as well as estimated the economic loss that follows its pathology. Several studies have indicated a high incidence of chronic osteoarticular pain in military service members, particularly in flight personnel. To date, no studies have estimated the incidence of pain pathology in the Italian military population, despite the implications related to flight qualification. Methods: A survey was conducted on helicopter flight personnel undergoing periodic annual evaluation. Results: A statistically significantly higher incidence of pain pathology than that reported in the global civilian population was demonstrated. More than 80% of the interviewed population reported moderate-to-severe back pain (45% in the lumbar tract and 38% in the cervical tract). Further, it was found that most staff with chronic pain do not use drugs or other treatments for severe pain because of concerns that such treatment approaches may compromise flight qualifications. Discussion: The present study observed a high incidence of pain in Italian military flight personnel and examined the degree to which this problem is undertreated in these individuals. To address this problem, further in-depth and larger investigations that include therapeutic protocols to resolve such pain pathologies should be conducted. Such investigations could help to reduce pain experienced by flight personnel and enhance the productivity of the Italian military forces while considering the pharmacologic limitations related to the task. Conclusion: Chronic lumbar and neck pain is more common in military helicopter crews than in the civilian population. The true figure is frequently underestimated because of staff concerns regarding the potential influence of therapies on work activity.

A Survey of Tranexamic Acid Use by US Tactical Emergency Medical Support Providers

McGuire SS, Klassen AB, Mullan AF, Sztajnkrycer MD 21(2). 72 - 76 (Journal Article)

Background: Tactical Emergency Medical Support (TEMS) providers may encounter severe traumatic injuries, with associated hemorrhagic shock, coagulopathy, and hyperfibrinolysis. Tranexamic acid (TXA) administration represents a potential intervention in this operational environment. This study evaluated TXA availability and use among US tactical medical personnel supporting law enforcement tactical teams. Methods: An anonymous on-line survey of the American College of Emergency Physicians (ACEP) Tactical Emergency Medicine (TEM) section was administered. Results: Fifty respondents were included in the final study. Fifty-four percent reported TXA availability, with 14% reporting its use at least once in the past year. Additional available resuscitative products included crystalloids (88%) and packed red blood cells (6%). Twenty-five respondents reported managing ≥ 1 patient(s) with hemorrhagic shock in the past year. Resuscitative measures included crystalloids (96%), TXA (68%), and blood products (16%). Overall, 88% of respondents were supportive of TXA use. Full-time teams, those with ≥ 3 monthly callouts, and teams that carried blood products were more likely to have TXA. Conclusions: Half of respondents reported managing a patient with hemorrhagic shock in the past year. Although 88% were supportive of TXA use, only 54% reported availability. Tactical teams with higher call volume and more resources were more likely to carry TXA. Further studies evaluating TEMS patient wounding patterns and barriers to TXA utilization are required.

A Case Study of Long-Range Rotary Wing Critical Care Transport in the Battlefield Environment

Eastman J, Dumont J, Green K 21(2). 77 - 79 (Journal Article)

Military medical evacuation continues to grow both in distance and transport times. With the need for long-range transport of greater than 2 hours, crews are having to manage critical care patients for longer trips. This case study evaluates one specific event in which long-range transport of a sick noncombat patient required an enroute critical care team. Medical electronics and other equipment require special attention. Oxygen bottles and batteries for medical devices become the limiting factor in transport from point to point. Having to juggle multiple data streams requires prioritization and reassessment of interventions. Using the mnemonic "bottles, bags, batteries, battlefield environment" keeps the transport paramedic and enroute care nurse on track to effectively deliver the patient to the next level of care. Consideration should be given to such mnemonics for long critical care transports.

Case Report of Infectious Myositis in the Austere Setting

Sarkisian S, Sletten ZJ, Roberts P, Powell T 21(2). 80 - 84 (Journal Article)

Although skin and soft tissue infections are common in the deployed setting, infectious myositis is relatively uncommon. Bacterial infection of the muscle is the most common infectious etiology and can result in a spectrum of disease, to include abscess formation to necrotizing myositis, toxic shock syndrome, and death. Diagnosis can be elusive, particularly in the early stages. Recognition and proper management are crucial to prevent complications. The authors present a case report of infectious myositis diagnosed and managed in an austere deployed environment, as well as a discussion regarding current recommendations on diagnosis and treatment.

Detection of Potential Pathogenic Bacteria on the Surfaces of Female Urinary Diversion Devices Following a Short Duration Military Training Exercise

Peters AM, Yu I, Menguito M, Morrow S, Barnhill JC, Washington MA 21(2). 85 - 88 (Journal Article)

Background: Female Servicemembers are increasingly being incorporated into the combat arms and Special Operations communities. Female urinary diversion devices (FUDDs) have been used to facilitate urination in the austere environments that are encountered by Servicemembers. Importantly, the potential for the bacterial contamination of these devices has not been evaluated. The goals of this study were to determine whether microorganisms adhere to the surfaces of FUDDs in the field environment and to demonstrate the presence of potential pathogens on the used devices. Materials and Methods: A total of 15 devices that were used in a comprehensive 18-24-hour military field exercise were tested for the presence of microorganisms. Briefly, each device was swabbed, and the swabs were used to inoculate blood agar plates to encourage bacterial growth. The resulting bacterial colonies were identified, and the surface topography of the devices was investigated with electron microscopy. Results: Although microscopy revealed few surface features capable of facilitating bacterial attachment, several species were recovered. Significantly, a biofilm-forming strain of Proteus mirabilis (P. mirabilis) was detected on two of the devices. P. mirabilis is a mobile urinary pathogen that can potentially migrate from the surface of the device into the urinary tract of the user. Conclusion: Commercial FUDDs can support bacterial growth and harbor potential pathogens. Care should be taken to ensure that Servicemembers are aware of the importance of the proper care and cleaning of these devices in the field environment. To this end, standard operating procedures should be developed and distributed.

Far-Forward Blood Donation and Donor Performance

Guilllotte CA, Schilling BK 21(2). 89 - 91 (Journal Article)

Fresh whole blood transfusion is advantageous when operating far-forward for both its availability and its physiological advantages over component therapy. However, the far-forward environment may place high physical performance demands on the donor immediately after donation. The aim of this paper was to briefly review the current literature on the effects of whole blood donation on a male donor's immediate physical performance after a standard donation volume of one unit (~450mL). Studies demonstrate reductions in peak volume of oxygen (VO2peak) of ~4% to 15% and time to exhaustion (TTE) of ~10% to 19% in the first 24 to 48 hours after donation. Anaerobic or cognitive performance has not been shown to decrease, but data on these parameters are limited. Donor physical performance decrements after a standard 450mL donation are minimal and may be mitigated through proper exercise training because training status may positively affect many variables that blood donation temporarily attenuates.

Intermittent Fasting: Can It Help Optimize Human Performance?

Deuster PA, Scott JM 21(2). 92 - 97 (Journal Article)

Nutritional fitness is a key goal of every Special Operations Forces (SOF) Operator, and nutrition is one way of potentially gaining a necessary edge. Although fad diets are popular among SOF Operators, many have no evidence with regard to military-specific tasks. One fad diet-intermittent fasting (IF)-is clearly the rage across the United States (US) and popular as a dietary pattern. Most fad diets are studied in the context of various chronic diseases, in particular, cardiovascular disease, diabetes, and obesity, and there are no data on the benefits among SOF or any military population. Thus, evidence demonstrating improvements in performance is typically lacking. Despite no clear evidence, many still devote their lives to popular fad diets. We address whether IF confers performance improvements in SOF by first discussing the concepts of metabolic flexibility and metabolic shifting, then describing IF and its subtypes, after which we summarize the literature with regard to cardiovascular disease and obesity. We close with how IF impacts performance and discuss who should use consider using IF as a dietary pattern.


Crecelius EM, Burnett MW 21(2). 98 - 99 (Journal Article)

Human brucellosis can be caused by different Brucella spp. When conducting operations in a country with high rates of brucellosis, extra precautions should be taken. Appropriate personal protective measures should be used in situations when close contact with animal carcasses cannot be avoided. Clinical diagnosis, treatment, and prevention are discussed.

Vitamin A and Bone Fractures: Systematic Review and Meta-Analysis

Knapik JJ, Hoedebecke BL 21(2). 100 - 107 (Journal Article)

Vitamin A is a generic term for compounds that have biological activity similar to that of retinol and includes carotenoids like ß-carotene and α-carotene. Some studies suggest high dietary intake of vitamin A can increase bone fracture risk. This investigation involved a systematic review and meta-analysis examining the association between vitamin A and fracture risk. Published literature was searched to find studies that (1) involved human participants, (2) had prospective cohort or case-control study designs, (3) contained original quantitative data on associations between dietary intake of vitamin A and fractures, and (4) provided either risk ratios (RRs), odds ratios (ORs), or hazard ratios (HRs) with 95% confidence intervals (95% CIs) comparing various levels of vitamin A consumption to fracture risk. Thirteen studies met the review criteria. Meta-analyses indicated that risk of hip fracture was increased by high dietary intake of total vitamin A (RR = 1.29; 95% CI = 1.07-1.57) or retinol (RR = 1.23; 95% CI = 1.02-1.48). Hip fracture risk was reduced by high dietary intake of total carotene (RR = 0.62; 95% CI = 0.42-0.93), ß-carotene (RR = 0.72; 95% CI = 0.58-0.89), or α-carotene (RR = 0.81; 95% CI = 0.67-0.97). Total fracture risk was not associated with any vitamin A compound. High intake of total vitamin A or retinol increased hip fracture risk, while high intake of some carotenoids reduced hip fracture risk.

Fresh Whole Blood Transfusion: Perspectives From a Federal Law Enforcement Agency Tactical Program

Kemp SJ, Levy MJ, Knapp JG, Steiner LA, Tang N 21(2). 108 - 111 (Journal Article)

A Brief Introduction to Phases of Clinical Medical Research for the SOF Medic

Merkle A, Randles J 21(2). 112 - 114 (Journal Article)

This is the first of an ongoing series to provide a background into reading medical research literature for the SOF medic.

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