Special Issues on Intraosseous Medicine - Part 2

Peripheral intravenous (IV) access can be difficult to achieve in critically ill patients who require vascular access in order to administer life-saving blood products, fluids and medications, especially in disasters and combat casualty care. Intraosseous access (IO) has become the standard of care for all medical emergencies, pre-hospital and hospital, when peripheral IV access cannot be rapidly established, and the techniques have been endorsed by multiple professional medical organizations. Research is rapidly expanding, both in the indications for IO, routes of administration, and clinical outcomes of intraosseous administration. The American Journal of Disaster Medicine is pleased to have the opportunity to publish two Special Issues1 focusing on current intraosseous research studies.

Download Full-text

The ABCs of Ocular Trauma: Adapting a Familiar Mnemonic for Rapid Eye Exam in the Pre-Ophthalmic Zone of Care

Military Medicine ◽

10.1093/milmed/usz262 ◽

2020 ◽

Vol 185 (Supplement_1) ◽

pp. 448-453

Author(s):

Christiaan F Kroesen ◽

Matthew Snider ◽

James Bailey ◽

Adam Buchanan ◽

James W Karesh ◽

...

Keyword(s):

Contact Lenses ◽

Care Practice ◽

Contact Lens Wear ◽

Eye Trauma ◽

Combat Casualty ◽

Ocular Ultrasound ◽

Medical Emergencies ◽

Joint Trauma ◽

Combat Casualty Care ◽

Lens Wear

Abstract Evaluation and management of eye trauma is daunting to many practitioners. For general medical emergencies, the familiar ABCs mnemonic serves to both recompose the provider as well as provide a logical order for evaluation and action. We recently adapted an ABCs mnemonic to provide non-ophthalmologists with a familiar method for systematically evaluating and managing eye trauma. A = ACUITY. Visual acuity is the most importance piece of information in eye trauma. B = BEST exam of BOTH eyes. Starting with acuity, examination proceeds from the front to the rear of the eye. Examine the uninjured eye first. C = CONTIGUOUS STRUCTURES and CONTACT LENSES. Examine structures contiguous to the apparent injury. Inspect for contact lens wear. D = DRUGS, DIAGNOSTIC IMAGING, and the DON’TS. Start antibiotics, antiemetics, and analgesics. Administer tetanus. Obtain computerized tomography if available. Do not attempt ocular ultrasound or magnetic resonance imaging. Do not apply pressure to the eye. Do not patch the eye or apply any medication. E = EYE SHIELD and EVACUATE. Shield and ship to ophthalmology. The mnemonic was adapted to reflect current Joint Trauma Services and Tactical Combat Casualty Care practice guidelines. We believe this familiar mnemonic will serve as a useful tool in allowing non-ophthalmologists to comfortably and safely evaluate an eye for trauma.

Download Full-text

Trends in Prehospital Blood, Crystalloid, and Colloid Administration in Accordance With Changes in Tactical Combat Casualty Care Guidelines

Military Medicine ◽

10.1093/milmed/usab461 ◽

2021 ◽

Author(s):

Emily E Clarke ◽

James Hamm ◽

Andrew D Fisher ◽

Michael D April ◽

Brit J Long ◽

...

Keyword(s):

Injury Severity ◽

Blood Product ◽

Guideline Implementation ◽

Fluid Administration ◽

Blood Products ◽

Tactical Combat Casualty Care ◽

Combat Casualty ◽

Original Dataset ◽

Freeze Dried ◽

Combat Casualty Care

ABSTRACT Introduction Hemorrhage is the leading threat to the survival of battlefield casualties. This study aims to investigate the types of fluids and blood products administered in prehospital trauma encounters to discover the effectiveness of Tactical Combat Casualty Care (TCCC) recommendations. Materials and Methods This is a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry with a focus on prehospital fluid and blood administration in conjunction with changes in the TCCC guidelines. We collected demographic information on each patient. We categorized receipt of each fluid type and blood product as a binary variable for each casualty and evaluated trends over 2007–2020 both unadjusted and controlling for injury severity and mechanism of injury. Results Our original dataset comprised 25,897 adult casualties from January 1, 2007 through March 17, 2020. Most (97.3%) of the casualties were male with a median age of 25. Most (95.5%) survived to hospital discharge, and 12.2% of the dataset received fluids of any kind. Medical personnel used crystalloids in 7.4% of encounters, packed red blood cells in 2.0%, and whole blood in 0.5% with very few receiving platelets or freeze-dried plasma. In the adjusted model, we noted significant year-to-year increases in intravenous fluid administration from 2014 to 2015 and 2018 to 2019, with significant decreases noted in 2008–2009, 2010–2012, and 2015–2016. We noted no significant increases in Hextend used, but we did note significant decreases in 2010–2012. For any blood product, we noted significant increases from 2016 to 2017, with decreases noted in 2009–2013, 2015–2016, and 2017–2018. Overall, we noted a general spike in all uses in 2011–2012 that rapidly dropped off 2012–2013. Crystalloids consistently outpaced the use of blood products. We noted a small upward trend in all blood products from 2017 to 2019. Conclusions Changes in TCCC guidelines did not immediately translate into changes in prehospital fluid administration practices. Crystalloid fluids continue to dominate as the most commonly administered fluid even after the 2014 TCCC guidelines changed to use of blood products over crystalloids. There should be future studies to investigate the reasons for delay in guideline implementation and efforts to improve adherence.

Download Full-text

Emergency Vascular Access (DRAFT)

10.1093/med/9780190612474.003.0025 ◽

2018 ◽

Author(s):

Rajagopala Padmanabhan ◽

Holt N. Murray

Keyword(s):

Critically Ill ◽

Vascular Access ◽

Critically Ill Patients ◽

Rapid Response Team ◽

Venous Access ◽

Critically Ill Patient ◽

Blood Products ◽

Life Saving ◽

Peripheral Venous Access ◽

Response Team

Emergency resuscitation and stabilization of the critically ill patient is a cornerstone of patient care during a rapid response team (RRT) call. The establishment of vascular access, along with airway, breathing, and circulation management is pivotal for the delivery of fluid, blood products, and life-saving medications that can directly impact the morbidity and mortality of critically ill patients. Unfortunately, peripheral venous access may be difficult, if not impossible, to get in some patients. In these, and other select situations, excess time spent attempting to insert a peripheral line can delay essential therapies. In this chapter, the indications, types, and methods of establishing vascular access will be reviewed briefly.

Download Full-text

Synthetic blood and blood products for combat casualty care and beyond

Journal of Trauma and Acute Care Surgery ◽

10.1097/ta.0000000000003248 ◽

2021 ◽

Vol Publish Ahead of Print ◽

Author(s):

Andrew P. Cap ◽

Jeremy W. Cannon ◽

Michael C. Reade

Keyword(s):

Blood Products ◽

Combat Casualty ◽

Combat Casualty Care

Download Full-text

Telemedicine Technology: Will It Enhance Combat Casualty Care on the 21st Century Battlefield?

10.21236/ada326784 ◽

1997 ◽

Author(s):

Donald J. Kasperik

Keyword(s):

21St Century ◽

Combat Casualty ◽

Telemedicine Technology ◽

Combat Casualty Care

Download Full-text

An analysis of 13 years of prehospital combat casualty care – implications for maintaining a ready medical force

Prehospital Emergency Care ◽

10.1080/10903127.2021.1907491 ◽

2021 ◽

pp. 1-12

Author(s):

Steven G Schauer ◽

Jason F Naylor ◽

Andrew D Fisher ◽

Michael D April ◽

Ronnie Hill ◽

...

Keyword(s):

Combat Casualty ◽

Combat Casualty Care

Download Full-text

Medical Challenges in Underground Warfare

Military Medicine ◽

10.1093/milmed/usaa447 ◽

2021 ◽

Vol 186 (Supplement_1) ◽

pp. 839-844

Author(s):

Alex Sorkin ◽

Roy Nadler ◽

Adir Sommer ◽

Avishai M Tsur ◽

Jacob Chen ◽

...

Keyword(s):

Cohort Study ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Trauma Registry ◽

Smoke Inhalation ◽

Expert Committee ◽

Medical Support ◽

Response Planning ◽

Combat Casualty ◽

Combat Casualty Care

ABSTRACT Introduction Throughout history, underground systems have served military purposes in both offensive and defensive tactical settings. With the advance of underground mining, combat tactics, and weapon systems, providing medical support in the subterranean battlefield is a constantly growing challenge. This retrospective cohort study describes the Israeli Defense Force (IDF) Medical Corps experience with treating casualties from underground warfare, as recorded in the IDF Trauma Registry. Methods A retrospective cohort study of all casualties engaged in underground warfare, between the years 2004-2018. Medical data were extracted from the IDF Trauma Registry and tactical data were obtained from operational reports. An expert committee characterized the most prevalent challenges. Recommendations were based on a literature review and the lessons learned by the IDF experience. Results During the study period, 26 casualties were injured in the underground terrain. Of casualties, 12 (46%) due to blast injuries, 9 (35%) were due to smoke inhalation, and 5 (19%) due to crushing injuries. All were males, and the average age was 21.6 years. Ten (38%) were killed in action (died before reaching a medical facility). All 16 casualties reaching the hospital survived (Table I). The expert committee divided the most common challenges into three categories—tactical, environmental, and medical. An overview of medical response planning, common injuries, and designated combat casualty care are discussed below. As in all combat casualty care, the focus should be on safety, bleeding control, and rapid evacuation. Conclusion To plan and provide medical support, a thorough understanding of operational planning is essential. This manuscript presents the evolution of underground warfare, tactical and medical implications, environmental hazards, and common casualty care challenges.

Download Full-text

Rationing, racism and justice: advancing the debate around ‘colourblind’ COVID-19 ventilator allocation

Journal of Medical Ethics ◽

10.1136/medethics-2020-106856 ◽

2021 ◽

pp. medethics-2020-106856

Author(s):

Harald Schmidt ◽

Dorothy E Roberts ◽

Nwamaka D Eneanya

Keyword(s):

Medical Knowledge ◽

State Level ◽

Standard Of Care ◽

Black Communities ◽

Racial Justice ◽

Life Saving ◽

Black Patients ◽

The Usa ◽

Alternative Measures ◽

The Way

Withholding or withdrawing life-saving ventilators can become necessary when resources are insufficient. In the USA, such rationing has unique social justice dimensions. Structural elements of dominant allocation frameworks simultaneously advantage white communities, and disadvantage Black communities—who already experience a disproportionate burden of COVID-19-related job losses, hospitalisations and mortality. Using the example of New Jersey’s Crisis Standard of Care policy, we describe how dominant rationing guidance compounds for many Black patients prior unfair structural disadvantage, chiefly due to the way creatinine and life expectancy are typically considered.We outline six possible policy options towards a more just approach: improving diversity in decision processes, adjusting creatinine scores, replacing creatinine, dropping creatinine, finding alternative measures, adding equity weights and rejecting the dominant model altogether. We also contrast these options with making no changes, which is not a neutral default, but in separate need of justification, despite a prominent claim that it is simply based on ‘objective medical knowledge’. In the regrettable absence of fair federal guidance, hospital and state-level policymakers should reflect on which of these, or further options, seem feasible and justifiable.Irrespective of which approach is taken, all guidance should be supplemented with a monitoring and reporting requirement on possible disparate impacts. The hope that we will be able to continue to avoid rationing ventilators must not stand in the way of revising guidance in a way that better promotes health equity and racial justice, both to be prepared, and given the significant expressive value of ventilator guidance.

Download Full-text