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The Use of the Abdominal Aortic and Junctional Tourniquet Versus Combat Gauze in a Porcine Hemicorporectomy Model

Schwartz RB, Shiver SA, Reynolds BZ, Lowry J, Holsten SB, Akers TW, Lyon M 19(2). 69 - 72 (Journal Article)

Background: Junctional hemorrhage is a potentially preventable cause of death. The Abdominal Aortic and Junctional Tourniquet (AAJT) compresses major vascular structures and arrests blood flow in exsanguinating hemorrhage. In a human model, the AAJT was effective in stopping blood flow in the femoral arteries via compression of the distal aorta. This study compares the ability of AAJT and Combat Gauze (CG) to stop hemorrhagic bleeding from a hemicorporectomy in a swine model. Method: Six anesthetized swine were used. Carotid arterial catheters were placed for continuous mean arterial pressure (MAP) readings. A hemicorporectomy was accomplished with a blade lever device by cutting the animal through both femoral heads transecting the proximal iliac arteries and veins. Hemorrhage control was attempted with the AAJT and regular Kerlix gauze or CG packing and direct pressure followed by Kerlix gauze placed over the CG. The primary outcome measure was survival at 60 minutes. Results: The 60-minute survival was 100% for the AAJT and 0% for the CG group. During the 60-minute monitoring period, only one CG animal achieved hemostasis. For the AAJT group, the mean time to hemostasis was 30 seconds. Initial MAP was higher in the AAJT group (mean, 87mmHg) than the CG group (mean, 70mmHg). The mean 60-minute MAP was 73mmHg for the AAJT group. Mean blood loss at 5 minutes and mean total blood loss were greater in the CG group than in the AAJT group. Conclusion: AAJT is superior to CG in controlling hemorrhage in a junctional wound in a swine model.

Resilience and Suicide in Special Operations Forces: State of the Science via Integrative Review

Rocklein Kemplin K, Paun O, Godbee DC, Brandon JW 19(2). 57 - 66 (Journal Article)

Background: Due to alarming rates of suicide in Special Operations Forces (SOF) and associated effects of traumatic stress in military populations writ large, resilience initiatives thought to influence Servicemembers' mitigation of traumatic stress and thus lower suicide risks have been implemented throughout the services. Since combat operations commenced in multiple theaters of war nearly two decades ago, resilience in conventional military populations became a topic of keen interest throughout departments of defense worldwide as well. Despite researchers' consistent assertions that SOF are highly resilient and at low risk for suicide, granular analysis of pertinent research and escalating suicide in SOF reveals no empirical basis for those beliefs. Methods: We report findings from an integrative review of resilience research in SOF and larger military populations to contextualize and augment understanding of the phenomenon. Results: Throughout the literature, conceptual and operational definitions of resilience varied based on country, context, investigators, and military populations studied. We identified critical gaps in resilience knowledge in the military, specifically: Resilience has not been studied in SOF; resilience is not concretely established to reduce suicide risk or proven to improve mental health outcomes; resilience differs when applied as a psychological construct; resilience research is based on specific assumptions of what composes resilience, depending on methods of measurement; resilience studies in this population lack rigor; research methodologies and conflicting interests invite potential bias. Conclusion: This integrative review highlights emergent issues and repetitive themes throughout military resilience research: resilience program inefficacy, potential investigator bias, perpetuated assumptions, and failure to capture and appropriately analyze germane data. Because of overall inconsistency in military resilience research, studies have limited external validity, and cannot be applied beyond sampled populations. Resilience cannot be responsibly offered as a solution to mitigating posttraumatic stress disorder nor suicide without detailed study of both in SOF.

Best Tourniquet Holding and Strap Pulling Technique

Wall PL, Buising CM, Donovan S, McCarthy C, Smith K, Renner CH 19(2). 48 - 56 (Journal Article)

Background: Appropriate strap pressure before tightening-system use is an important aspect of nonelastic, limb tourniquet application. Methods: Using different two-handed techniques, the strap of the Generation 7 Combat Application Tourniquet (C-A-T7), Tactical Ratcheting Medical Tourniquet (Tac RMT), Tactical Mechanical Tourniquet (TMT), Parabelt, and Generation 3 SOF® Tactical Tourniquet-Wide (SOFTTW) was secured mid-thigh by 20 appliers blinded to pressure data and around a thigh-sized ballistic gel cylinder by gravity and 23.06kg. Results: Pulling only outward (90° to strap entering buckle) achieved the lowest secured pressures on thighs and gel. For appliers, the best holding location was above the buckle, and the best strap-pulling direction was tangential to the thigh or gel (0° to strap entering buckle). Preceding tangential pulling with outward pulling resulted in higher secured pressures on the gel but did not aid appliers. Appliers generally did not reach secured pressures achievable for their strength. Of 80 thigh applications per tourniquet, 77 C-A-T7, 41 Tac RMT, 35 TMT, 16 Parabelt, and 10 SOFTTW applications had secured pressures greater than 100mmHg. Conclusions: The default for best tourniquet strap-application technique is to hold above the buckle and pull the strap tangential to the limb at the buckle. Additionally, neither strength nor experience guarantees desirable strap pressures in the absence of pressure knowledge.

Ease of Use of Emergency Tourniquets on Simulated Limbs of Infants: Deliberate Practice

Kragh JF, Wright-Aldossari B, Aden JK, Dubick MA 19(2). 41 - 47 (Journal Article)

Background: To investigate questions about application of emergency tourniquets in very young children, we investigated practices of Combat Application Tourniquet (C-A-T) use on a simulated infant-sized limb to develop ways to improve readiness for caregiving. Methods: This study was conducted as investigations of C-A-Ts used by two individuals in deliberate practice. The practice setup simulating a limb of infants aged 3−5 months included a handrail (circumference, 5.25 in.). This setup needed a specific modification to the instructions for use to adhere the band between the clips. Each user performed 100 practices. Results: With accrual of experience, application time was shorter for each user, on average in a power law of practice, and more ease was associated when less time was taken to apply the tourniquet. The ease of use was associated with accrued experience through deliberate practice of a tourniquet user while under coached learning. A check of tourniquet fit on a 4.25-in. limb also entailed the modification used in the 5.25-in. limb. However, an additional modification of wrapping the band in a figure-8 pattern around the rod was needed because the rod and clip could not meet. The fit on a 3.25-in. limb was impracticable for a workaround. Tourniquet use was harder for smaller limbs (i.e., 4.25 in. and 3.25 in.). A map of tourniquet fit was sketched of which sized limbs were too big, too small, within the fit zone, or at its borders. Conclusion: C-A-Ts mechanically fit the simulated limbs of infants aged 3−5 months, and C-A-T use was practicably easy enough to allow experienced users to fit tourniquets to limbs well using a specific modification of the routine technique. The findings and knowledge generated in this study are available to inform researches and developments in best preparation practices for instructing first aid.

Use of Atomized Intranasal Tranexamic Acid as an Adjunctive Therapy in Difficult-to-Treat Epistaxis

Sarkar D, Martinez J 19(2). 23 - 28 (Case Reports)

There is a growing body of literature on the safe, effective use of tranexamic acid (TXA) for hemostasis in a variety of clinical settings. We present a case series of three patients with difficult-to-treat epistaxis where standard treatment methods were not effective. Using atomized intranasal TXA (ATXA) as part of a stepwise treatment approach, we were able to achieve hemostasis and manage all three cases independently, and we did so without major complications in our emergency department (ED). Given recent literature showing the underuse of TXA in combat casualties, ATXA, if formulated and delivered properly, may be of benefit for epistaxis and other significant hemorrhage cases. Further work must be done to elucidate the mechanism of action, specific dose, delivery method, use indications, and safety profile of ATXA.

Differential Diagnosis of an Unusual Snakebite Presentation in Benin: Dry Bite or Envenomation?

Benjamin JM, Chippaux J, Jackson K, Ashe S, Tamou-Sambo B, Massougbodji A, Akpakpa OC, Abo BN 19(2). 18 - 22 (Case Reports)

A 20-year-old man presented to a rural hospital in Bembéréké, northern Benin, after a witnessed bite from a small, dark snake to his left foot that occurred 3 hours earlier. The description of the snake was consistent with several neurotoxic elapids known to inhabit the area in addition to various species from at least 10 different genera of non-front-fanged colubroid (NFFC) venomous snakes. The presentation was consistent with the early signs of a neurotoxic snakebite as well as a sympathetic nervous system stress response. Diagnosis was further complicated by the presence of a makeshift tourniquet, which either could have been the cause of local signs and symptoms or a mechanical barrier delaying venom distribution and systemic effects until removal. Systemic envenomation did not develop after the removal of the constricting band, but significant local paresthesias persisted for longer than 24 hours and resolved after the administration of a placebo injection of normal saline in place of antivenom therapy. This was an unusual case of snakebite with persistent neuropathy despite an apparent lack of envenomation and a number of snakebite- specific variables that complicated the initial assessment, diagnosis, and treatment of the patient. This case presentation provides clinicians with an opportunity to familiarize themselves with the differential diagnosis and approach to a patient bitten by an unidentified snake, and it illustrates the importance of symptom progression as a pathognomonic sign during the early stages of a truly serious snake envenomation. Treatment should be based on clinical presentation and evolution of symptoms rather than on snake identification alone.

Mottled, Blanching Skin Changes After Aggressive Diving

Lau AM, Johnston MJ, Rivard R 19(2). 14 - 17 (Case Reports)

The initial livedo skin changes of cutis marmorata, also known as cutaneous decompression sickness (DCS), are transient in nature. Accordingly, early images of violaceous skin changes with variegated, marbled, or mottled appearance are rare, whereas later images of deep, erythematous, or violaceous skin changes are readily available. This case presents the opportunity to view the early skin changes characteristic of cutaneous DCS, which would likely manifest at Level I care in the setting of a diving injury during Special Operations missions in austere environments. The unique diving context also allows an overview of DCS in addition to a review of skin eruptions associated with various marine life. As diving is frequently used by Naval Special Warfare, topics presented in this case have significant relevance to Special Operations.

ATP-P Handbook - 9th Ed en Espanol (978-0-9966297-2-0)

La novena versiõn Ed español del Protocolo Paramédico Tãctico Avanzado (ATP-P) Manual incluye un ĩndice de español a las palabras y frases de uso comõn Inglés médicas.

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Winter 2018 Journal (Vol 18 Ed 4)

Vol 18 Ed 4
Winter 2018 Journal of Special Operations Medicine
ISSN: 1553-9768

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Adapting to Death: Clarifying the Roles of Special Operations Combat Medics in Prolonged Field Care

Jeschke EA 18(4). 153 - 156 (Journal Article)

I suggest that Special Operations Forces (SOF) medicine should explicitly acknowledge the Special Operations combat medic's role in attending death. This acknowledgment will allow researchers to evaluate and delimit the medic's needs in relationship to an expanded set of roles that move beyond life-saving care. This article comprises four sections. First, I provide background to my argument by exploring some assumptions of modern medicine and objections to exploring battlefield death care. Second, I describe how I see the medic's role expanding with the introduction of prolonged field care. Third, I address the implications of the medic's expanded role in relationship to role and function stress and strain. Fourth, I address the moral complexity related to withdrawing or withholding care. I conclude by briefly highlighting some of the implications for future research. In explicitly engaging death as a medical reality for which the medic ought to be prepared, SOF medicine could set the foundational development for seeing death as a valuable gift to be explored, not a failure to be avoided or burden to be overcome.

Thrown for a Loop

Urbaniak MK, Hampton K 18(4). 148 (Journal Article)

Effects of Oral Glucosamine Sulfate on Osteoarthritis-Related Pain and Joint-Space Changes: Systematic Review and Meta-Analysis

Knapik JJ, Pope R, Hoedebecke SS, Schram B, Orr R, Lieberman HR 18(4). 139 - 147 (Journal Article)

Background: Osteoarthritis (OA) is a disorder involving deterioration of articular cartilage and underlying bone and is associated with symptoms of pain and disability. Glucosamine is a component of articular cartilage naturally synthesized in the body from glucose and incorporated into substances contained in the cartilage. It has been suggested that consumption of glucosamine may reduce the pain of OA and may have favorable effects on structural changes in the cartilage. This article presents a systematic review and meta-analysis of the effectiveness of orally consumed glucosamine sulfate (GS) on OA-related pain and joint structural changes. Methods: PubMed and Ovid Embase were searched using specific search terms to find randomized, double-blinded, placebo-controlled trials on the effects of GS on pain and/or joint-space narrowing. The outcome measure was the standardized mean difference (SMD), which was the improvement in the placebo groups minus the improvement in the GS groups divided by the pooled standard deviation. Results: There were 17 studies meeting the review criteria for pain, and the summary SMD was -0.35, with a 95% confidence interval (95% CI) = -0.54 to -0.16 (negative SMD is in favor of GS). Of the 17 studies, 7 showed a statistically significant reduction in pain from GS use. Four studies met the review criteria for joint space narrowing with a summary SMD = -0.10 (95% CI = -0.23 to +0.04). Studies without involvement of the commercial glucosamine industry had a lower (but still significant) pain reduction efficacy (summary SMD = -0.19, 95% CI = -0.39 to -0.02) than those with industry involvement. Several smaller dosages throughout the day had larger pain reduction effects than a single daily large dose (1500 mg). Conclusion: These data indicate that GS may have a small to moderate effect in reducing OA-related pain but little effect on joint-space narrowing. Until there is more definitive evidence, healthcare providers should be cautious in recommending use of GS to their patients. Because GS dosages used in studies to date resulted in mild and transient adverse effects, and these were similar to that experienced by patients receiving placebos, larger GS doses possibly could be investigated in future studies.


Burnett MW 18(4). 137 - 138 (Journal Article)

What the SOF Community Needs to Know About Dietary Supplements

Deuster PA 18(4). 131 - 136 (Journal Article)

Dietary supplement (DS) use by military members and Special Operations Forces (SOF), in particular, is high. The "sports nutrition" market is expected to be one of the fastest growing segments because a "performance edge" is certainly desirable within the military. DS products are readily available in retail stores on military bases, over the Internet, and in niche stores near military bases. Thus, use of some DSs raises a number of unique concerns, particularly considering the potential for interactions among combinations of DS ingredients and concurrent medications taken under military operational conditions. All those who work with SOF should have a basic understanding of the DS world. This article briefly reviews selected DS regulations, identifies concerns and risks related to various DS products, and describes the purpose, functions, and resources of Operation Supplement Safety. Examples of regulatory concerns, adverse events, red flags, and tools are provided to help SOF communities sustain their health and performance.

Clinical Update: Concepts of Prehospital Traumatic Hemorrhage Control in the Operational K9

Palmer LE 18(4). 123 - 130 (Journal Article)

Major trauma often involves varying degrees of hemorrhage. Left unattended, any amount of trauma-induced hemorrhage may rapidly become life threatening. Similar to humans, Operational canines (OpK9s) can suffer penetrating trauma and blunt trauma that lead to compressible and noncompressible hemorrhage. Preserving organ function and saving the life of a massively bleeding OpK9 require the implementation of immediate and effective hemostatic measures. Effective hemorrhage control interventions for the exsanguinating OpK9 are similar to those for humans: direct pressure, wound packing, hemostatic agents and devices, pressure bandage, and, possibly, tourniquet application. Although tourniquet application is a life-saving intervention in humans experiencing extremity hemorrhage, it is not considered a necessary, immediate-action life-saving intervention for canines with extremity injuries. This article provides a brief description of the basic methods for identifying life-threatening hemorrhage and achieving immediate hemostasis in the bleeding OpK9 during the prehospital period.

Efficacy of the Abdominal Aortic Junctional Tourniquet-Torso Plate in a Lethal Model of Noncompressible Torso Hemorrhage

Bonanno AM, Hoops HE, Graham T, Davis BL, McCully BH, Wilson LN, Madtson BM, Ross JD 18(4). 106 - 110 (Journal Article)

Background: The Abdominal Aortic Junctional Tourniquet, when modified with an off-label, prototype, accessory pressure distribution plate (AAJT-TP), has the potential to control noncompressible torso hemorrhage in prolonged field care. Methods: Using a lethal, noncompressible torso hemorrhage model, 24 male Yorkshire swine (81kg-96kg) were randomly assigned into two groups (control or AAJT-TP). Anesthetized animals were instrumented and an 80% laparoscopic, left-side liver lobe transection was performed. At 10 minutes, the AAJT-TP was applied and inflated to an intraabdominal pressure of 40mmHg. At 20 minutes after application, the AAJT-TP was deflated, but the windlass was left tightened. Animals were observed for a prehospital time of 60 minutes. Animals then underwent damage control surgery at 180 minutes, followed by an intensive care unit-phase of care for an additional 240 minutes. Survival was the primary end point. Results: Compared with Hextend, survival was not significantly different in the AAJT-TP group (ρ = .564), nor was blood loss (3.3L ± 0.5L and 3.0L ± 0.5L, respectively; p = .285). There was also no difference in all physiologic parameters between groups at the end of the study or end of the prehospital phase. Three of 12 AAJT-TP animals had an inferior vena cava thrombus. Conclusion: The AAJT-TP did not provide any survival benefit compared with Hextend alone in this model of noncompressible torso hemorrhage.

The Benefits of Reflexology for the Chronic Pain Patient in a Military Pain Clinic

Kern C, McCoart A, Beltranm T, Martoszek M 18(4). 103 - 105 (Journal Article)

Background: Chronic pain is a major cause of disability across the military, especially for the combat Soldier. More than twothirds of Americans with chronic pain are now using complementary medicine. Methods: Patients with chronic pain opting for reflexology as part of their treatment plan received bilateral therapy. Alternating pressure was applied to the individual patient's reflex points corresponding to their pain sites. Following a single treatment session, patients were asked to complete a short survey. Discussion: There is evidence that reflexology is therapeutic for many conditions, to include sleep and anxiety, both of which can be comorbidity in the patient with chronic pain. There is a lack of evidence on the use of reflexology with chronic pain patients receiving multidisciplinary pain care. Results: A total of 311 participants completed the survey. Posttreatment pain scored decreased by a median of 2 points (interquartile range [IQR] 1-3) on a 10-point pain scale. This represents a median 43% (IQR 25%-60%) reduction in pain for males and a 41% (IQR 30%-60%) reduction in pain for females. Conclusion: Currently research is limited on effects of reflexology in treating chronic pain, yet, like acupuncture, this is an inexpensive, reliable, teachable, and simple noninvasive treatment. Further studies are warranted.

A Novel, Perfused-Cadaver Simulation Model for Tourniquet Training in Military Medics

Grabo DJ, Polk T, Strumwasser A, Inaba K, Foran C, Luther C, Minneti M, Kronstedt S, Wilson A, Demetriades D 18(4). 97 - 102 (Journal Article)

Background: Exsanguinating limb injury is a significant cause of preventable death on the battlefield and can be controlled with tourniquets. US Navy corpsmen rotating at the Navy Trauma Training Center receive instruction on tourniquets. We evaluated the effectiveness of traditional tourniquet instruction compared with a novel, perfused-cadaver, simulation model for tourniquet training. Methods: Corpsmen volunteering to participate were randomly assigned to one of two tourniquet training arms. Traditional training (TT) consisted of lectures, videos, and practice sessions. Perfused-cadaver training (PCT) included TT plus training using a regionally perfused cadaver. Corpsmen were evaluated on their ability to achieve hemorrhage control with tourniquet(s) using the perfused cadaver. Outcomes included (1) time to control hemorrhage, (2) correct placement of tourniquet(s), and (3) volume of simulated blood loss. Participants were asked about confidence in understanding indications and skills for tourniquets. Results: The 53 corpsmen enrolled in the study were randomly assigned as follows: 26 to the TT arm and 27 to the PCT arm. Corpsmen in the PCT group controlled bleeding with the first tourniquet more frequently (96% versus 83%; p < .03), were quicker to hemorrhage control (39 versus 45 seconds; p < .01), and lost less simulated blood (256mL versus 355mL; p < .01). There was a trend toward increased confidence in tourniquet application among all corpsmen. Conclusions: Using a perfused- cadaver training model, corpsmen placed tourniquets more rapidly and with less simulated-blood loss than their traditional training counterparts. They were more likely to control hemorrhage with first tourniquet placement and gain confidence in this procedure. Additional studies are indicated to identify components of effective simulation training for tourniquets.

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