Combat & Casualty Care

Q1 2017

Military Magazines in the United States and Canada, Covering Combat and Casualty Care, first responders, rescue and medical products programs and news\Tactical Defense Media

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study from OIF and OEF indicated that truncal non-compressible hemorrhage accounted for about 67 percent of deaths from potentially survivable injuries. Although use of body armor has mitigated torso injuries, they still occur. Currently, there is nothing short of giving some resuscitation fluid to try and keep the blood pressure above a Mean Arterial Pressure of 60-65 mmHg (palpable radial pulse) to maintain perfusion to vital organs without increasing bleeding. Laboratory research has shown repeatedly that some fluid is necessary to maintain casualties from severe hemorrhage. The current top CoTCCC recommendations for resuscitation fluids include whole blood, plasma and 1:1 ratio of plasma and red blood cells or 1:1:1 ratio if platelets are also available. Although crystalloids such as Plasma-Lyte or colloids such as Hextend are still on the recommended list, minimal volume should be administered so as to minimize hemodilution of blood clotting factors that may worsen developing coagulation dysfunctions. Another important factor in stabilizing the casualty is body temperature. It has been shown that if the patient arrives to a treat- ment facility with hypothermia, they have a much higher mortality rate. Keeping the casualty warm in the pre-hospital environment is a challenge. Several warming devices and fluid warmers are available, but many require power. However, there are warming products such as the Hypothermia Prevention and Management Kit that supplies a chemical heating blanket and wrap that provides warmth for several hours. In addition there are several battery-powered warming blan- kets, but they may have significant weight. Nevertheless, research shows that these devices work more efficiently at maintaining body temperature than actually warming the person. Therefore, every effort should be made to prevent hypothermia from developing in austere environments. A very important approach to improve survivability is rapid transport to a treatment facility. It has been shown that survival is improved when transport times from point-of-injury to definitive care was less than 60 minutes compared to greater than 60 min- utes. The ability to transport casualties rapidly is best achieved by having a command-directed trauma system established so the right casualty goes to the right treatment facility in the least amount of time. Establishing and maintaining such a system even in a mature battlefield remains a challenge, but clearly has been shown to be a major advance in improving survival of the severely injured. C&CC: Feel free to speak to other current/forward-looking techniques in use by USAISR for addressing the need to minimize non-survivable casualty numbers due to combat hemorrhage. Dr. Dubick: Research into improved hemorrhage control continues so that no casualty dies from a potentially survivable injury. Several companies continue to work on improving hemostatic dressings, including products that may be used internally and would be bioabsorbable. Efforts are also underway to further refine wound packing techniques which have seen little attention previously. In addition, efforts to develop or improve new or existing tourniquets are focused on making them easier to use and efforts continue to investigate pneumatic tourniquets to extend their application into pre-hospital situations. With respect to both limb and junctional tourniquets, important aspects of their safety and effectiveness have recently identified user performance as a key element. Thus research continues in improving training, understanding learning curves and minimizing skill decay of both instructors and users of these devices. As mentioned, a major issue is treating non-compressible torso hemorrhage. Resuscitative Balloon Occlusion of the Aorta is being investigated as an endovascular approach to hemorrhage control where a balloon catheter is inserted through the groin into differ- ent zones of the aorta to maintain circulation to the brain, lung and heart and stop lower body bleeding until the bleeding location can be repaired. Other products such as hemostatic foams and other devices to address non-compressible torso hemorrhage are under development. Approaches involving neural stimulation of select nerves are also being investigated to reduce blood flow and bleeding from torso hemorrhage. It is important to recognize that many of the current products have been investigated only for short periods of time or under rapid evacuation times. With new scenarios such as prolonged field care where evacuations times will easily exceed one hour, new devices and treatment regimens will be required and evaluated under realis- tic battlefield scenarios. This highlights the importance of the Joint Trauma System that was established at the U.S. Army Institute of Surgical Research at Fort Sam Houston, Texas, early into OIF. Its focus on data collection of casualties and performance improve- ment is centered on clinical outcomes, the ultimate endpoint of any hemorrhage control strategy. In this way the trauma care experience from conflicts is captured, integrated into the research program at USAISR and then systematically translated into striving for best care of the warfighter. www.tacticaldefensemedia.com 14 | Combat & Casualty Care | Spring 2017

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