Applying Pharmacogenomic Guidelines to Combat Medical Care

ABSTRACT Pharmacogenomics is a pillar of personalized medicine that has the potential to deliver optimized treatment in many medical settings. Military medicine in the deployed setting is unique and therefore warrants separate assessment pertaining to its potential capabilities and impact. Pharmacogenomics for United States Active Duty Service Members medical care in the deployed setting has not, to our knowledge, been previously reviewed. We present potential applications of pharmacogenomics to forward medical care through two comprehensive references for deployed medical care, the Tactical Combat Casualty Care Guidelines (TCCC) and Emergency War Surgery (EWS) fifth edition. All drugs within the deployment manuals, TCCC guidelines and EWS book, were identified and the list was cross-referenced to the Clinical Pharmacogenetics Implementation Consortium guidelines and genes–drugs interactions list as well as the Food and Drug Administration Table of Pharmacogenomics Biomarkers in Drug Labeling. Ten pharmacologic categories were identified, consisting of 15 drugs, along with the classes, aminogylcosides, beta-blockers, and volatile anesthetics. Drugs and pharmacogenomics liabilities were tabulated. Eight specific drugs or classes are expounded upon given the belief of the authors of their potential for impacting future treatment on the battlefield in the setting of prolonged field care. This review outlines several genes with liabilities in the prolonged field care setting and areas that may produce improved care with further study.

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

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.

Evaluating the Tactical Combat Casualty Care principles in civilian and military settings: systematic review, knowledge gap analysis and recommendations for future research

ObjectivesThe Tactical Combat Casualty Care (TCCC) guidelines detail resuscitation practices in prehospital and austere environments. We sought to review the content and quality of the current TCCC and civilian prehospital literature and characterize knowledge gaps to offer recommendations for future research.MethodsMEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials were searched for studies assessing intervention techniques and devices used in civilian and military prehospital settings that could be applied to TCCC guidelines. Screening and data extraction were performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Quality appraisal was conducted using appropriate tools.ResultsNinety-two percent (n=57) of studies were observational. Most randomized trials had low risk of bias, whereas observational studies had higher risk of bias. Interventions of massive hemorrhage control (n=17) were wound dressings and tourniquets, suggesting effective hemodynamic control. Airway management interventions (n=7) had high success rates with improved outcomes. Interventions of respiratory management (n=12) reported low success with needle decompression. Studies assessing circulation (n=18) had higher quality of evidence and suggested improved outcomes with component hemostatic therapy. Hypothermia prevention interventions (n=2) were generally effective. Other studies identified assessed the use of extended focused assessment with sonography in trauma (n=3) and mixed interventions (n=2).ConclusionsThe evidence was largely non-randomized with heterogeneous populations, interventions, and outcomes, precluding robust conclusions in most subjects addressed in the review. Knowledge gaps identified included the use of blood products and concentrate of clotting factors in the prehospital setting.Level of evidenceSystematic review, level III.

Combat Casualty Care

To deliver combat casualty care to warfighters, multinational forces deploy medical units to provide immediate front-line treatment, transfer the injured to in-theater combat hospitals, and evacuate the critically wounded to Europe and the United States. With bed space limited, Coalition medical facilities developed medical rules of eligibility to regulate the flow of multinational patients, host-nation allies, detainees, and local civilians. While multinational patients received unreserved medical attention, local nationals were, at best, only eligible for emergency care before transfer to poorly equipped local facilities. Despite legal provisions that stipulate impartial care based solely on urgent medical need, medical personnel attended to patients based on national identity and military status. Military necessity sometimes permits treating moderately injured warfighters before the critically ill to return the former to duty. Appealing to associative duties, however, allows military medical providers to deliver preferential care to compatriots despite urgent medical need elsewhere.

Combating the “Peacetime Effect” in Military Plastic Surgery: Implications for Mission Readiness

ABSTRACT Military treatment facility-assigned surgeons face numerous challenges in maintaining critical wartime skills, including the “peacetime effect” and the “dual mission.” Using the field of plastic surgery to illustrate these issues, we contrast plastic surgeons’ contributions to combat casualty care with primary data describing plastic surgeons’ clinical practice in many military hospitals. Then, we outline the current administrative mechanisms being promoted at the enterprise-level for surgeons to gain a more mission-focused, clinical practice, while also examining significant shortcomings in these policies. Finally, we conclude with a call to action for the military surgical community to accelerate change in the development of more robust clinical practices for our surgeons, or potentially lose our ability to field a ready surgical force.