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REVIEWARTICLE Military medical revolution: Deployed hospital and en route care Lorne H. Blackbourne, MD, David G. Baer, PhD, Brian J. Eastridge, MD, Evan M. Renz, MD, Kevin K. Chung, MD, Joseph DuBose, MD, Joseph C. Wenke, PhD, Andrew P. Cap, MD, Kimberlie A. Biever, MS, Robert L. Mabry, MD, Jeffrey Bailey, MD, Christopher V. Maani, MD, Vikhyat Bebarta, MD, Todd E. Rasmussen, MD, Raymond Fang, MD, Jonathan Morrison, MD, Mark J. Midwinter, MD, Ramo´n F. Cestero, MD, and John B. Holcomb, MD INTRODUCTION for the patient population with severe abdominal injuries1 and has gained widespread acceptance. In the civilian trauma The battlefield has seen tremendous revolutions in mili- systems, this trilogy usually occurs in one hospital. This ap- tarymedicalaffairs(RMMAs)asaresultofthe lastdecadeof proach has been described for all anatomic injuries in the se- continuous combat operations. The advances in deployed and verelyinjuredpatientatriskforphysiologicdecompensation.2,3,4 en route combat casualty care are categorized as individual In contrast to the civilian damage control, global combat RMMAsshowninTable 1. Aswith prehospital advances, the damage-controlsurgeryofteninvolvesmultipleseparatesurgical basis for many of the RMMAs in the deployed hospital care facilities,multiplesurgeons,multipleresuscitationandstabiliza- environment as well as en route care was translated from ci- tionepisodes,helicopterevacuation,andfixed-wingevacuations vilian trauma practice but is realistic and relevant to the bat- by the Critical Care Air Transport Team (CCATT) during a tlefieldcontext.Astheconflictevolved,thesubstantivedatafrom multistageglobaltransit(Fig. 1).4Y5 the battlefield led to many new paradigms of treatment and Global combat damage control has been successfully evacuation. The successful implementation of many of these conducted for thousands of combat-wounded patients within a battlefieldpracticeswastheneffectivelytranslatedbackintothe matter of several days and represents a profound revolutionary civilian injury care environment as has been typical of medical changeinthecareofpatientsseverelywoundedincombat. advancesdevelopedsubsequenttopreviousconflictsofantiquity. The RMMAs that occurred during the last 10 years of combat casualty care are in the realm of deployed hospital care Damage-Control Resuscitation anden route care andare discussed in detail in this article. Damage-control resuscitation (DCR) is one of the most significant RMMAs to develop from the overseas contingency operations (OCOs) in Iraq and Afghanistan. As introduced in a DEPLOYED HOSPITAL CARE 2007specialcommentarybyHolcombetal.,6DCRisdescribed as‘‘astructuredintervention[which]beginsimmediatelyafter Global Combat Damage-Control Surgery rapid initial assessment in the ED and progresses through Damage-control surgery is well established in civilian theORintotheICU.Alleffortsaredirectedtowardsthisgoal traumacentersandisdescribedasthetrilogyofabbreviatedop- of preventing/correcting hypothermia, acidosis, and coagulo- eration, intensive care stabilization/resuscitation, and the return pathybyrepeatedpointofcaretestingandtheuseofmultiple to the operating room for the last or multistage procedures for blood products and drugs readily available in theater, albeit thedefinitivesurgicalrepair.Thisparadigmhasreducedmortality innewratiosandamounts.’’DCRconsistsoftwomajorefforts as follows:permissive hypotensiontopreventexcessive bleeding and hemostatic resuscitation, which stresses the administration FromtheUSArmyInstituteofSurgicalResearch(L.H.B.,D.G.B.,B.J.E.,E.M.R., ofbloodproductsina1:1:1manner.5 K.K.C., J.C.W., A.P.C., K.A.B., R.L.M., J.B., C.V.M., T.E.R.); MEDCOM Mosttraumapatientsarenotcoagulopathicanddonotre- (V.B.),BrookeArmyMedicalCenter,FortSamHouston;USNavy(R.F.C.), NavalMedicalResearchUnit SanAntonio,SanAntonio;UniversityofTexas quire blood product resuscitation. However, up to 25% of se- HealthScienceCenteratHouston(J.B.H.),Houston,Texas;BaltimoreCenter verelybleedingtraumapatientspresentwithacutecoagulopathy, for theSustainmentofTrauma andReadiness Skills(CSTARS)(J.D.),Uni- and mortality in these patients can be as high as 50%. During versityofMarylandMedicalCenter,Baltimore,Maryland;USAirForce(R.F.), LandstuhlRegionalMedicalCenter,Landstuhl,Germany;andRoyalCentre thecourseofthelastdecade,theUSmilitarymedicalcommunity forDefenceMedicine(JM,M.J.M.),Birmingham,UnitedKingdom. has developed the concept of DCR to treat this subset of criti- Theopinionsorassertionscontainedhereinaretheprivateviewsoftheauthorand cally injured patients. This revolutionarychange improved doc- are not tobe construed asofficial or as reflecting theviewsof the US De- trinedevelopedinthelatterhalfofthe20thcentury. partmentoftheArmy,Navy,orAirForceortheUSDepartmentofDefense. Addressforreprints:LorneH.Blackbourne,MD,USArmyInstituteofSurgical The cornerstone of the DCR revolution is the aggressive Research,FortSamHouston,TX78234-6315;email:lorne.h.blackbourne@ useofbloodproductsincludingpackedredbloodcells(PRBCs), us.army.mil. fresh frozen plasma (FFP), and platelets in ratios near 1:1:1. DOI:10.1097/TA.0b013e3182754900 Military studies conducted during the Iraq war suggested that JTraumaAcuteCareSurg S378 Volume73,Number6,Supplement5 Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Report Documentation Page Form Approved OMB No. 0704-0188 Public reporting burden for the collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Washington Headquarters Services, Directorate for Information Operations and Reports, 1215 Jefferson Davis Highway, Suite 1204, Arlington VA 22202-4302 Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to a penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number 1. REPORT DATE 2. REPORT TYPE 3. DATES COVERED 01 DEC 2012 N/A - 4. TITLE AND SUBTITLE 5a. CONTRACT NUMBER Military medical revolution: deployed hospital and en route care 5b. GRANT NUMBER 5c. PROGRAM ELEMENT NUMBER 6. AUTHOR(S) 5d. PROJECT NUMBER Blackbourne L. H., Baer D. G., Eastridge B. J., Renz E. M., Chung K. K., Dubose J. J., Wenke J. C., Cap A. P., Biever K. A., Mabry R. L., Bailey J., 5e. TASK NUMBER Maani C. V., Bebarta V. S., Rasmussen T. E., Fang R., Morrison J. J., Midwinter M. J., Cestero R. F., Holcomb J. B., 5f. WORK UNIT NUMBER 7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES) 8. PERFORMING ORGANIZATION United States Army Institute of Surgical Research, JBSA Fort Sam REPORT NUMBER Houston, TX 9. SPONSORING/MONITORING AGENCY NAME(S) AND ADDRESS(ES) 10. SPONSOR/MONITOR’S ACRONYM(S) 11. SPONSOR/MONITOR’S REPORT NUMBER(S) 12. DISTRIBUTION/AVAILABILITY STATEMENT Approved for public release, distribution unlimited 13. SUPPLEMENTARY NOTES 14. ABSTRACT 15. SUBJECT TERMS 16. SECURITY CLASSIFICATION OF: 17. LIMITATION OF 18. NUMBER 19a. NAME OF ABSTRACT OF PAGES RESPONSIBLE PERSON a REPORT b ABSTRACT c THIS PAGE UU 10 unclassified unclassified unclassified Standard Form 298 (Rev. 8-98) Prescribed by ANSI Std Z39-18 JTraumaAcuteCareSurg Volume73,Number6,Supplement5 Blackbourneetal. subgroup receiving TXA (28.1% vs. 14.4%; p = 0.004). TABLE1. RMMAs,2001to2011OCOsinAfghanistanand Multivariate regression modeling of the massive transfusion Iraq. cohort showed that TXA use was independently associated OCO RMMA withsurvival(oddsratio[OR],7.28;95%confidenceinterval [CI],3.02Y17.32).TXAisthefirsttargetedtherapytobeproven Deployedhospitalcare DCR effective in hemorrhaging trauma patients, and CRASH-2 pro- Diagnosticevaluationfor explosioninjury vides Level I evidence to support its use. TXA has been incor- Vascularsurgery poratedintotheJointTraumaSystemCPGforDCRandhasbeen Orthowoundcare recommended as an option prehospital by the Committee on RegionalanesthesiaandTIVA Tactical Combat Casualty Care and the Defense Health Board Combatburncare (DHBmemo,TXA). ManagementofTBI Diagnostic Evaluation for Explosion Injury Surgicalinterventionfor penetratingTBI Current practice for evaluating and treating penetrating Negative-pressurecombat injurytotheabdomen,flank,andpelvishasundergoneadrastic wounddressings and profound change during OCOs. From World War I until IntravenousTXA 2004,atenetofmilitarysurgerywastoexploreallpatientswith Far-forwardMIS abdominalpenetratinginjury.10Y12 The advent of computed to- Coagulationmonitoringwith mographic(CT)scanonthebattlefieldinRole3facilitieshas thromboelastography/RoTEM allowed visualization of the position of metallic fragments in Enroutecare Globalenroutecare(CCATT penetrating abdominal injury patients. Beekley et al.13 de- andBurnFlightTeam) scribe the successful nonoperative treatment of up to 60% of Enroutecriticalcarenursing stable patients with penetrating fragments to the abdomen in USArmyflightmedictraining theabsenceoffrankperitonealsignsonphysicalexamination andnointraperitonealor retroperitonealpenetrationofthefrag- ments. With an available CT scanner, the mandate of surgical exploration for all penetrating abdominal wounds has been patients receiving higher ratios of FFP to PRBCs had lower abandoned.TheCTscannerhasthussuccessfullyrevolutionized mortalityrates(19%vs.65%)comparedwiththosewhoreceived lower ratios (1:8).6 Similar results have been found in the ci- thecareofcombatwoundedwithpenetratingabdominalinjuries by avoiding iatrogenic morbidity associated with negative ex- vilian setting, where a retrospective analysis of patients re- ploratorylaparotomies. ceivingmassivetransfusionsfoundalowermortality(26%vs. 87.5%) in those who received FFP/PRBC in a higher ratio.7 Vascular Surgery CurrentmilitaryDCRclinicalpracticeguidelines(CPGs)state The revolution invascular injury management during the that, ‘‘The goaloftransfusionofthepatientwithneedformas- warsinAfghanistanandIraqhasatitscoretheresolutejoining sivetransfusionistodeliveraratioofPRBCstoplasmatopla- of combat-wounded patients with surgeons soon after the time telets of 1:1:1.’’8 As soon as patients arrive to the emergency of injury. This paradigm has been sustained because of a com- department and are identified as likely to require massive binationoflife-preservingtacticalcombatcasualtycare,strategic transfusion, the DCR protocol is initiated; thawed plasma is positioning of forward surgical capability, and use of rapid usedasaprimaryresuscitationfluidina1:1ratiowithPRBCs. This process continues through the operating room and into theintensivecareunit.Crystalloiduseistherebysignificantly limited, as are other resuscitative adjuncts such as cryopreci- pitate and tranexamic acid (TXA). TXA in Trauma Resuscitation The landmark CRASH-2 trial testing the safety and effi- cacyofTXAintraumaresuscitationmarkedaturningpointinthe treatmentoftraumapatients.Forthefirsttime,asinglepharma- ceutical intervention was shown to reduce mortality in hemor- rhaging trauma patients. This study documented the benefit of TXAinreal-worldclinicalpracticeacrossawidevarietyofset- tings, including austere environments. Reinforcing the revolu- tionaryfindingsofCRASH-2,ananalysisofearlyuseofTXAby United Kingdom physicians at the North Atlantic Treaty Orga- nization Role 3 Bastion hospital in Afghanistan documented similarresultsincombatcasualties.9 In this study of 896 casu- alties,32.7%(n=293)receivedTXA,while67.2%(n=603)did not. The patients receiving TXA had a higher survival rate (82.6% vs. 76.1%; p = 0.028) than the massive transfusion Figure1. Globalcombatdamage-controlsurgery. *2012LippincottWilliams&Wilkins S379 Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. JTraumaAcuteCareSurg Blackbourneetal. Volume73,Number6,Supplement5 medicalevacuation(MEDEVAC)withinaJointTraumaSystem. poweredpindriverareused.Thispracticehasbeenproventobe This model of uniting a salvageable patient with a surgeon at a asafeandeffectivemeansofprovidinginitialstabilization.36The capablefacilityminutesafterinjuryrepresentsaprofoundchange useofexternalringfixationhasbecomecommon,particularly inhowvasculartraumaismanaged.Evidenceofthisnewpara- inthemostseverewoundsandresultsinlowcomplicationrates. digm is found in epidemiologic studies that report the rate of vascular injuryonthe modernbattlefield to be five to six times Regional Anesthesia and Total Intravenous higherthantheratereportedinpreviouswars.14Y16Thesestudies Anesthesia capturethephenomenonofpatientssurvivingtoarriveatsurgical Combatpainmanagementhaschallengedclinicianscaring facilitiestohavetheirinjuriesrecordedandtreated.Furthermore, forwoundedwarriorsfromthepointof injuryonthebattlefield for the first time in modern war, many of these decisions are throughMEDEVACandevenintertiarycarefacilities.Subopti- madebysurgeonswithsubspecialtyvascularandcardiovascular malanalgesiamaybeassociatedwithlong-termsequelaesuchas training.17 posttraumatic stress disorder, depression, sleep disturbances Withinthisnewparadigm,therevolutionofmilitarymed- (nonrestorative sleep patterns), and chronic pain syndromes.37 ical affairs as they pertain to vascular disruption, hemorrhage, Recentadvanceshaveallowedpatientstobenefitfromoptimized and/or ischemia on the battlefield encompasses the following: paincontrolasaresultof increasedfocusoncombatpainman- forward deployment of subspecialty trained peripheral vascular agement. Four such notable advances include the total intrave- surgeons,15,17 definition of a neuromuscular ischemic thresh- nousanesthesia(TIVA)movement,theadoptionofthepumpfor old of the limb (G5 hours),18,19 the need for expedited reper- regionalanesthesia,theuseoforaltransmucosalfentanylcitrate fusion following extremity vascular injury and ischemia,20,21 (OTFC),andtheMilitaryPainCareAct. reconstruction of vascular injury using saphenous vein as the The ability to provide TIVA significantly reduces the lo- conduitofchoice,15,20repairofproximalwatershedextremity gistic and equipment constraints on anesthesia providers. This vein injuries,15,22 ligation of select minor or distal extremity becomesespeciallyimportantincombatandotherausteremed- vascular injuries (arterial and venous),14,23 necessity of viable icinesettings,whereeveryeffortismadetoreducetheburdenof tissue coverage of vascular reconstruction to prevent disrup- requiredequipmentandsupplies.Forwardsurgicalteamsarenow tion,24,25 temporary shunts as an adjunct to accomplish reper- equipped with automated syringe infusion pumps, and staff are fusion or venous outflow rapidly,26Y28 endovascular techniques trained in their use as part of a balanced TIVA anesthetic. The to treat select patterns of vascular injury or disruption,29,30 and pairing of pain pumps and regional/neuraxial anesthesia techni- endovascular balloon occlusion as a hemorrhage control or re- ques is another clear example of combat pain control improve- suscitationadjunct.31Y33 mentthroughuseofamedicalforcemultiplier.Thesebattlefield TheseadvancesmadeduringthedecadeofwarinAfgha- patientcontrolledanalgesiapumpsareroutinelyusedtocontrol nistan and Iraq have been a result of the modern paradigm in pain in combat casualties during transport on military aircraft. whichasalvageablepatientisevacuatedtoasurgeonatacapable Advanced regional anesthesia techniques have been extremely facilitywithinminutesafterinjury.Inaggregate,theseadvances effective for acute pain management, especially pain from ex- representaprofoundchangeinhowvascularinjuryismanaged tremity injuries and rib fractures. Such techniques include con- inmoderncombat. tinuous epidurals, continuous peripheral nerve blocks, and continuoustransversesabdominisplaneblocks.Theadvantages Orthopedics of regional analgesia include significant decrease in pain with Likeotheraspectsofcasualtycare,orthopedicsurgeryhas profoundopioidsparing.38,39 profoundly changed since the Vietnam War. Since 82% of all OTFC has also been used in theater. It is easily adminis- soldierswoundedinactionnotreturningtodutyhaveatleastone tered without need for intravenous access, and a single 400-Hg extremityinjury,thesechangeshaveasignificantimpactonbattle doseismore potentwithmore effective analgesiathan5mgto casualties.34 Damage-control orthopedics refers to an approach 10 mg of morphine delivered intramuscularly. OTFC affords thatisdesignedtonotplacethemostseverelyinjuredpatientsat both quick relief from buccal absorption and prolonged relief furtherriskbyaggressiveearlytotalcare.Thecommonpracticeis fromgastrointestinalabsorption.Althoughrespiratorydepression early, rapid, temporary stabilization of a fracture to minimize remains a concern, combat medics devised and implemented a blood loss, then physiologic stabilization, and finally definitive safetyfeaturedesignedtodecreaseriskofnarcosisbytapingthe orthopedicmanagement.35Thestepsinthispracticehavebeen stickendofthebuccallozengetothecasualty’sfinger,resulting shown to be successful for unstable patients. The practice of ingravity-dependentwithdrawalofthemedicationifthepatient combatdamagecontrolorthopedicsisanecessityforvirtually becomesoversedated. all extremity injuries and not just for soldiers who are in Guiding policies and legislation often do not have as ob- extremis. Temporary external fixation is the most common vious or as tangible an impact as the resurgence of TIVA and initial fixation method, which is often converted to internal regional anesthesia techniques; nevertheless, the Military Pain fixation when a wounded soldier is returned to the United CareActof2008prioritizedpaincareasanationalpriorityand States.Thistemporaryapproachtodamagecontrolisamajor brought the focus to efforts to improve quality of analgesia. In change from the Vietnam War, where casualties were often August 2009, the Pain Management Task Force was commis- treated in the combat theater for weeks before being sent to sioned to provide comprehensive pain management strategies. theUnitedStates. BySeptember2010,thisteamcomposed109recommendations During the initial steps of the evacuation chain, spanning geared toward a comprehensive pain management policy. The externalfixationandaprepackagedpeelpackcontainingahand- commandguidanceforprioritizationofoptimalpaincontrolwith S380 *2012LippincottWilliams&Wilkins Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. JTraumaAcuteCareSurg Volume73,Number6,Supplement5 Blackbourneetal. avoidanceofchronicpainsequelae,combinedwithregionalan- theKoreanWar,andthistherapyiswidelyconsideredtobeone esthesia and TIVA and target-controlled infusion technology, ofthekeyRMMAsinthehistoryofcombatcasualtycareduring representssignificantadvancesinanesthesiaandpaincontrolfor thatconflict.46 During OCOs, advances in this arena have in- thecombatwounded.Thiswilltranslateintoimprovedoutcomes volvedtheapplication of continuous renal replacementthera- forinjuredsoldiers,sailors,airmen,andmarines. py (CRRT) in the most severely injured. The impact of acute kidney injury on mortality in patients with burn injury has Combat Burn Care been between 80% and 100% during the last few decades, DespitemanyadvancessincetheVietnamera,fewaspects evenwithdialysis.NotuntilthecurrentOCOshasCRRTbeen related to the treatment of the burn casualty create a greater used to address this problem. Before November 2005, only challengefortheproviderthantheprocessofresuscitationduring conventionalhemodialysiswas availablefor critically ill burn thefirst24hoursto48hoursfollowinginjury.Militarycasualties casualtieswhodevelopedacutekidneyinjury,buttheywerenot with severe burns often have other injuries, and these can sig- offered these services most of the time because of their hemo- nificantly complicate care. The challenges associated with fluid dynamic instability. For this reason, a CRRT program was de- resuscitation of the military burn casualty can be greater for veloped in November 2005 with an emphasis on continuous deployed providers, who are often unaccustomed to caring for venovenoushemofiltration.Resultsweredramaticwithabsolute patientswithsevereburns. reductions in in-hospital mortality (compared with historical Itis in the area of burnresuscitation that the militaryhas control)of32%inthecombat-injuredpatients47and24%when madegreatstridesintheabilitytoprovideearlyresuscitationof combining all patients (both civilian and combat).48 These the burncasualty. These efforts haveyielded resultsthatcanbe observationshavespawnedamulticentertrialevaluatingcontin- declaredhighlysuccessful,ifnotrevolutionary,intheirimpact. uous venovenous hemofiltration in burns49 and application and Among the lessons learned early in the war in Iraq was furtherdeploymentofCRRTcapabilityintheaterandGermany.50 that there was significant variability in the administration of fluids with overresuscitation being more common than under- Burn Care resuscitation, often with devastating outcomes.40 This observa- Themostcommonlyusedtopicalantimicrobialagentsin- tion led to two major improvements in military burn care, cludesilversulfadiazineandsulfamyloncream.51Newertopical implementationoftheBurnResuscitationFlowSheetanduseof treatment modalities include dressings that contain silver a simplified formula appropriately called the Rule of Ten.41,42 particles within their fibers, which can release silver anions. Observations made as part of the Joint Theater Trauma System Thesilver providesbroadspectrumprotectionofthedressing (JTTS) performance improvement process led to creation and against microbial contamination and serves as an antimicro- standardizationofasimpleformdesignedtobeinitiatedbythe bialbarrier.52Theabilitytowrapsilver-impregnateddressings initial care team and accompany the patient throughout the on burn casualties decreases the frequency of dressing chan- evacuation continuum. Documentation of fluids of all varieties ges, which is often beneficial during the long-range transport andthequantitiesofeachfluidinfusedallowedproviderstomore of patients between theater and the US-based care facility. easily recognize the cumulative nature of the resuscitative pro- Thesedressingsareusedincombinationwithnegative-pressure cess. This seemingly simple act proved to be a significant con- wound dressings (NPWDs) to prepare wound beds for grafting tributorinimprovingtheresuscitationprocess.43Onthecoattails and secure grafts once in place.53 NPWDs are now used at the oftheburnflowsheetcametheotherimportantchangetothe levelofthecombatsurgicalhospital(Role3)andbeyond.This burn resuscitation processVdevelopment and fielding of the option allows surgeons to debride complex wounds, place the Rule of Ten.44 The initial fluid rate is calculated by multiply- NPWDintheoperatingroom,andleaveitsecurelyinplacefor ingtheestimatedburnsize(totalburnsurfacearea[TBS])by severaldaysifneeded. 10 mL/h. Initial fluid rate ¼ TBS (cid:1) 10 mL=h: Skin Replacement Improvementsinresuscitationandmorerapidtransportof The Rule of Ten simplifies the calculation of an initial burncasualtiesfromthewarzonehaveresultedinburnsurvivors fluid resuscitation rate and emphasizes that fluid infusion rate withlargerwoundsrequiringcoverage.Toachieverapidwound needs to be adjusted based on the patient’s response. Further closure for patients with full-thickness burns that do not allow advances related to monitoring of resuscitation continue in the immediateautologouscoverage,theuseofbiosyntheticmaterials formofBurnResuscitationDecisionSupportSystem(BRDSS) software.45 Computer-basedtoolssuchasBRDSSarebeingde- and/orculturedtissuemaybebeneficial. Integrahasbeenusedasaneodermisforpatientswithfull- veloped and are nearing approval from the US Food and Drug thickness skin loss and can be covered with autologous skin or Administration(FDA)forlarge-scalefielding.Preliminaryanal- culturedepidermalautografts.54 Cultured epidermal autografts ysisoftheeffectivenessofBRDSSprototypesstronglysuggests that we will see major benefit from these tools to aid burn re- have been used to treat several US military burn casualties with burns inexcessof85% TBS. suscitationinthenearfuture. Renal Replacement Therapy Prevention Early and aggressive application of renal replacement Aswithalltraumaticinjuries,effectivepreventiondeserves therapytosupportseverelyillcombat-injuredpatientswithrenal ourbestefforts.Thebenefitsofmitigatingthermalinjurycannot failureisnotanewconcept.Thefirstsuchreportsdatebackto be overstated. Analysis of combat injuries early in the war in *2012LippincottWilliams&Wilkins S381 Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. JTraumaAcuteCareSurg Blackbourneetal. Volume73,Number6,Supplement5 Iraq and Afghanistan revealed that hand burns were among the hypertonicsaline(HTS)has,inparticular,beenintroducedwith most prevalent thermal injuries encountered. Rapid fielding of theintenttoimproveTBIoutcome.HTSisaparticularlyattrac- improved flame-resistant gloves showed great effectiveness in tivefluidchoiceforpatientswithTBIforseveralreasons.Ithas reducing hand burns and subsequent disability.55 Similar im- been demonstrated that HTS may prove more effective in de- provements have been noted with the development of new creasing cerebral edema, compared with mannitol, owing to its flame-resistantuniforms.Issuanceoftheflame-resistantArmy higherosmotic reflection coefficient across the blood-brainbar- combatshirtandotheruniformitemswasalsocorrelatedwitha rier. HTS-mediated increases in capillary vessel inner diameter markedreductioninthermalinjuriesamongdeployedtroops. via dehydration of endothelial cells, coupled with decreased erythrocytevolumesecondarytodehydration,mayalsopromote Management of Traumatic Brain Injury increasedbloodflowtoregionsofthebrainmostatriskforsec- Traumatic brain injury (TBI) remains a common compo- ondary injury.58Y61 For this reason, the JTTS CPGs presently nent of injury patterns encountered in modern theaters of con- advocatetheadministrationof3%HTSinthispopulation.Using flict. The evolving military medical revolutions regarding this a strict protocol approach to the use of this management ad- entity have involved both improved recognition of the problem junct, 3% HTS has been used in the OCO environment over and improvements in the treatment of combat-related brain in- 6 years, with no documented adverse events. Following this jury. The spectrum of injury encountered may prove diverse, lead, similar successes have been reported in the civilian lit- encompassingbothmildandsevereinjurypatternswithassoci- eraturedocumentingthesafeuseofHTSamongbrain-injured atedvariabilityinsubsequentimpairment.Revolutionaryefforts civilians.62 to improve these outcomes have included improved screening attheearlieststagesafterinjury,resuscitativeadjunctsdesigned Surgical Intervention for Penetrating TBI tominimizesecondaryinjury,andimprovedselectionofopera- Theappropriatemanagementofpenetratingbraininjuries tivestrategiesdesignedtooptimizeoutcome. intheciviliantraumaenvironmenthasremainedanactivematter of investigation.63 Although some groups have proposed the Mild TBI Screening benefitsofaggressivepoliciesofcranialdecompressionfollow- In 2003, as hostilities in Operation Iraqi Freedom transi- ing penetrating mechanisms,64,65 these procedures carry ap- tioned from traditionalwarfare to insurgency, it became readily preciableriskforcomplications.66TheOCOcareofsevereTBI apparentthatthisnewenemytacticwasproducinglargenumbers patients remains unique because, in this environment, decom- ofcasualtieswithmildTBI(concussivebraininjury). pressiveinterventionsaremorecommonlyrequiredowingtothe Theinitialtooldevelopedtoscreenfor mildTBIwasthe concerns of potential intracranial pressure changes during aero- military acute concussion evaluation tool. This tool was devel- medical evacuation. This requirement for more aggressive sur- oped by the Defense and Veterans Brain Injury Center and in- gical approaches has, however, led to important discoveries cludedbothahistoryandanevaluationcomponent.Thehistory regarding the potential impact of liberal decompression on sur- component was used to requisite elements that were congruent vivalaftersevereTBI. with the potential diagnosis of mild TBI. The neurocognitive In arecentstudycomparingcivilianandmilitarypatients screeningcomponentofthemilitaryacuteconcussionevaluation with severe TBI, DuBose et al.67 found that matched military was developed from the standardized assessment of concussion patients were significantly more likely to both undergo inva- toassesstheneurologicdomainsoforientation,immediatemem- sive intracranial monitoring (13.8% vs. 1.7%, p G 0.001) and ory, concentration, and delayed recall.56,57 In 2007, the JTTS operative neurosurgical intervention (21.5% vs. 7.2%, p G publishedaTBICPGbasedontheDefenseandVeteransBrain 0.001). Mortality was also significantly less among military InjuryCenterworkgroup’sconsensus.Afterthedevelopmentof casualtiesoverall(7.7%vs.21.0%,pG0.001;OR,0.32[95% adefinedscreeningmethodology,formalneurocognitivescreen- CI, 0.16Y0.61]) and particularly following penetrating mechan- ing was introduced into the predeployment and postdeploy- ismsof injury(5.6%vs.47.9%,pG0.001;OR,0.07[95%CI, menthealthassessmentsin2007.In2009,VeteransAffairsand 0.02Y0.20])comparedwithpropensityscoreYmatchedcivilian the US Department of Defense partnered to develop a formal counterparts. This report, combined with ongoing military Defense Center of Excellence for Psychological Health and study, has raised awareness of the potential of aggressive de- Traumatic Brain Injury with the explicit goal of fostering compression to improve penetrating TBI outcome in the ci- improvements and minimizing practice variability in the man- vilian traumaenvironment. agementofbehavioralhealthandTBI. In 2010, a directive type memorandum (DTM 09-033), Negative-Pressure Combat Wound Dressings ‘‘Policy Guidance for the Management of Concussion/Mild Arguably, one of the most revolutionary advances in the Traumatic Brain Injury in the Deployed Setting,’’ was issued last 20 years has been the advent of negative-pressure wound toaddressbattlefieldmildTBI,includingestablishmentofman- therapy(NPWT)forthemanagementofcomplexwoundsbefore datory reporting events requiring mild TBI evaluations and definitiveclosure.NPWThasbeenreportedtodecreasetimeto reporting with the ultimate goals of improving early detection, closure,reduceinfection,anddecreaselaborrequiredfordressing appropriatetreatment,andavoidanceof injuryexacerbation. changes when used in the management of complex soft tissue woundssustainedincombat.68ApplicationofNPWTincomplex Hypertonic Saline Use in TBI contaminated soft tissue extremity injuries, even with the first Revolutions in resuscitation have also emerged as stan- debridement, owing to blast and penetrating injury as well as dardsofcareinpresentOCOs.Amongthesechanges,theuseof temporarymanagementofcomplexabdominalwounds,hasbeen S382 *2012LippincottWilliams&Wilkins Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. JTraumaAcuteCareSurg Volume73,Number6,Supplement5 Blackbourneetal. welldescribed.22,69,70 Inburns,useofNPWThasimprovedthe hyperfibrinolysis, requiring TXA (or additional doses of TXA). ability to dress wounds, prepare wound beds for grafting, and Bothtypesofpatientswouldpresentwithasimilarclinicalpic- securegraftsonceinplace.53 tureofdiffusemicrovascularbleeding.RoTEMisanewtoolin NPWTdressingsarenowusedatthelevelofthecombat themanagementofcombatcasualties.Itrequiresfurtherevalua- surgicalhospital(Role3)andbeyond.Thefeasibilityandsafety tionbutmayVinthenearfutureVfacilitatemoretargetedblood of NPWT during global air evacuation, an important advance, componentuseandreducetransfusionrequirements. hasalsobeenrecentlydescribed.71 Asingledressing compared with the multiple wet-to-dry dressing changes is a profound GLOBAL EN ROUTE CARE changeinthemanagementofcombatwounds. Critical Care Air Transport Team Far-Forward Minimally Invasive Surgery Globalen route care andtheUSAirForceCCATTsrev- Whereasmilitaryexperienceledtomanyoftheadvancesin olutionizedcombatcareforthecriticallyill.IntheVietnamWar, surgicalcare,theadvancementsmadeinminimallyinvasivesur- casualties were evacuated weeks after injury. In response to ca- gery(MIS)developedexclusivelyinthecivilianpeacetimesetting. sualty evacuation issues in Somalia in 1993, the US Air Force MIS usein the evaluation of low-energyabdominalpenetrating created a CCATT to augment aeromedical evacuation crews traumadevelopedowingtoitspotentialtime-to-recoveryadvan- whencriticallyillorinjuredpatientsweretransported.Themis- tage over open technique. Based on the civilian experience, sion of the team was to manage up to three high-acuity me- consensuswasreachedamongagroupofAirForcesurgeonsthat chanically ventilated patients or up to six less ill patients who MIS could offer a select population of the combat-injured or had received initial resuscitation but remained critically ill. The those in need of emergency general surgery avaluable surgical teamwasdesignedtotransportthetraumaticallyinjuredandthe alternative,providedthatthetechnologycouldbesafelyandef- medicallyill.Theteamiscomposedofaphysicianexperienced fectively deployed, operated, and maintained in the forward en- incriticalcare(emergencymedicine,intensivist,pulmonologist, vironment (unpublished report, Bowers S, Bailey J, Jenkins D, cardiologist, or anesthesiologist), a respiratory therapist, and a TheroleofMISintheforwardcombathospital,2008). critical care nurse. The team assumes care of the patient at a The first recorded successful minimally invasive forward LevelIIorLevelIIItheaterhospitalandmanagesthepatientuntil operation was a laparoscopic appendectomy performed at the arrival at the receiving hospital. The CCATT is equipped to Air Force Theater Hospital (AFTH) in Iraq in February 2006 care for patients and to diagnose and treat uncommon compli- (Personaloperatingroomcaselogs,AFTHIraqandCraigJoint cationssuchasacutehypoxia,respiratoryfailure,pneumothorax, Theater Hospital, Afghanistan). Following this operation, the and shock. Flights range from 1 hour (intratheater) to 18 hours initial experience with forward MIS was selectively expanded (transatlanticflights)andarecommonly6hoursto8hourslong. toincludediagnosticlaparoscopytoevaluateforperitonealpen- In the Vietnam War, patients would be evacuated from theater etration in fragment injury (eight, one conversion to open for to a remote hospital in 21 days; with the CCATTs, the average positive finding), appendectomy (eight), small-bowel adhesio- movement from injury is 28 hours and is frequently as few as lysis (two), and video thoracoscopy for decortication (one) and 12hours.77,78CCATTisconsideredoneofthemostimportant evacuation of retained hemothorax (two). Following this initial contributions to survival in Operation Iraqi Freedom and Op- experience, the demonstrated operability and advantage of MIS eration EnduringFreedom.77 in the forward setting led to growing acceptance and formal Since the beginning of Operation Enduring Freedom and sustaining of the capability throughout the remainder of the Operation Iraqi Freedom, approximately 16,000 missions have AFTH experience in Iraq and subsequently and to date at flown with 8,000 patients.79 Most patients are traumatically in- theCraigJointTheaterHospitalinAfghanistan. jured (40Y65%), and the remaining are medically ill. Approxi- mately50%areventilatedmechanically,10%receivevasoactive Thromboelastography and Rotational infusions, and 6% receive blood products in flight. Reversible Thromboelastometry hypotension and hypoxia are the most common complications. Bleeding is compounded by the presence of acute trau- Death,in-flightendotrachealintubations,andchestthoracostomy maticcoagulopathy,whichispresentinaquarterofcasualtiesand placements or flight diversions are rare.78Y80 In addition to quadruples mortality.72Y74 While the armamentarium of the cli- combattheaterevacuations,theCCATTmodelhasbeenused nician builds, knowing when to deploy these resources is less to develop the Acute Lung Rescue Team, a team with more clear. Conventional tests of coagulation, such as prothrombin advanced training and equipment for transporting patients timeandpartialthromboplastintime,areunsuitablefordirecting with severeacute lunginjury. bloodproductresuscitationbecausetheytaketimetoanalyze75 and provide an incomplete picture of coagulation status. This Burn Transport ledthe UK Defence Medical Service (DMS) to evaluate ro- US military medical crews capable of transporting criti- tational thromboelastometry (RoTEM) for point-of-care coag- cally injured burn casualties include the Air Force CCATTand ulation testing.76 RoTEM provides a rapid evaluation of a the Army’s Burn Flight Team (BFT). Both teams are capable patient’scoagulationprofile,allowingclinicianstotailorresusci- of transporting severely burned casualties autonomously, and tation.Forexample,areductioninmaximumclotfirmness(the both routinely use the transport capabilities of the C17 Globe- amplitude of the trace) would prompt a clinician to diagnose masterIIItacticaltransportaircraft. hypocoagulabilityandadministerplasmaorplatelets.Incontrast, TheArmy’sBFTflightmissionisgenerallyperformedby a sudden decay of an initially normal trace would suggest fivepersonnel:acriticalcaresurgeon,aregisterednurse,alicensed *2012LippincottWilliams&Wilkins S383 Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. JTraumaAcuteCareSurg Blackbourneetal. Volume73,Number6,Supplement5 vocationalnurse,arespiratorytherapist,andanoperationsnon- civilianemergencymedicalservices(EMS)systems.Coincident commissionedofficer.Thesizeandcompositionofadeploying with the development of modern civilian EMS systems were teamiseasilyadjustedaccordingtothenumberandcomplexity theendoftheVietnamWarandthedemobilizationofthephy- of the patients being transported. Patients with burn injury are sicians,nurses,andmedicswhoserved.Manyofthesereturning evacuated from the operational theater to Landstuhl Regional medicalprovidershelpeddevelopthecurrentEMSsystemsbased MedicalCenterinGermany.Fromhere,warcasualtiesrequiring ontheirwartimeexperiences. care in a burn center are transported from Landstuhl Regional Thecivilianmodelevolvedtobecomepatientcentric,fo- Medical Center to the USAISR Burn Center at San Antonio cusing on care delivered en route and training providers to a Military Medical Center at Fort Sam Houston, an 8,000 mile high level to provide that care in the unique environment of evacuationlastingapproximately16hoursinflight. the helicopter. The US Army’s model remained platform Since 2003, critically ill and injured casualties are trans- centric,focusingontheaircraft’sperformanceandoperations. ported both safely and expeditiously, usually arriving in a US- En route care in the Army was still provided by a single basedmedicalcenterassoonas3daysto4daysfollowinginjury. combat medic with basic emergency medical technician ca- This revolutionary change to definitive early care provided at pability,essentially inthesame fashion asit wasdoneduring theUSAISRBurnCenter(verifiedbytheAmericanBurnAsso- the Vietnam War. Thus, civilian EMS developed as a sophis- ciation)leveragestechnologicaladvances,whichincreasemedi- ticatedsystem,withaircraftgenerallystaffedbyapairofhighly cal capabilities during transport. With these technologies, the trained flight paramedics and/or flight nurses, whereas the US BFTcanprovideventilatorsupport,advancedmonitoring,state- Army staffs its MEDEVAC helicopters with a single EMT-Basic of-the-artfluidresuscitation,andclinicallaboratorytesting.This despiteacontemporaryoperationalenvironmentrequiring(1) ability to monitor blood physiology and organ function (e.g., transport of unprecedented numbers of civilians, including heart, lung, liver, and kidney) and cardiovascular dynamics is pediatric, geriatric, obstetric, and medical cases; (2) transport lifesaving. With these capabilities, patients can be safely trans- of postoperative critical care patients between facilities; and portedasaresultofthisabilitytopractice‘‘criticalcareintheair.’’ (3)transportacrosslargegeographicareasrequiringprolongedin- flightcare. En Route Critical Care Nursing Arecentstudycomparedpatientoutcomesbetweencasu- For the first time in history, military nurses have been alties evacuated by the conventional Army MEDEVAC system dedicated to the mission of rotary wing critical care transport andanArmyNationalGuardMEDEVACunitstaffedbycritical duringcombat.Flightnurseswereasignificantpartofthemili- caretrainedflightparamedicsusingprotocolsandstaffingmodels tary medical team and the fixed-wing transport system, which adopted for the combat environment based on current civilian continued beyond World War II into the Korean and Vietnam helicopter EMS practice in the United States.85 The National warsbeforeOCOs.Before2010,flightmedicsassignedtoavia- Guard unit using a civilian Helicopter Emergency Medical tion units and physicians and nurses assigned to deployed hos- Servicemodelwasassociatedwitha66%reductionintherisk pitalswouldoftentransportsignificantlyinjuredtraumapatients ofdeathat48hoursamongseverelyinjuredcasualties(Injury who had recently undergone DCR and initial operations to Severity Score [ISS] 916). This study, along with numerous manage their wounds. The nurses and physicians were selected After Action Reports from deployed units citing the need for forthemissionsonthebasisoftheirexperienceandtraining.For an increased level of training for flight medics, prompted the those patients requiring more specialized care and accompani- Army Medical Department to review its current flight medic mentbyanurseoraphysician,thathealthcareproviderwasre- training program and to initiate a new program to train all movedfromtheteamorhospital,sometimesforseveraldays.81Y83 flightmedicstothecivilianflightparamedicstandardby2017. Their removal proved particularly problematic in Afghanistan, leavingremotefacilitieswithfewpersonnel,makingitdifficultto sendnursesorphysicianswithcriticallyillorinjuredpatients.In 2010,theUSArmyNurseCorpsdedicatedateamofcriticalcare nurses to the mission of en route care for transport to Role 3 careinAfghanistan.Theenroutecriticalcarenursesarenow embeddedintheaviationunitsandprovidespecializedcareto the combat wounded.84 This has given nurses a unique op- portunity to collaborate with our out-of-hospital providers (Fig.2).ThiswasdoneroutinelyinIraqby2006,withnurses from US Navy, US Air Force, and US Army transporting patients from LevelII toIII and between LevelIII facilities. US Army Flight Medic Training Militaryphysicianshave long recognizedthatrapidevac- uationfromthebattlefielddecreasessufferingandpreventsdeath. Helicopter MEDEVAC underwent a significant expansion and growthduringtheVietnamera.Thesuccessofmilitarycasualty Figure2. CPTAprilRitter(left),enroutecriticalcarenurse,and careledtothepassageoftheNationalHighwaySafetyActand aflightmedicassignedtotheC/3-82DustoffoutofJalabad, prompted Congress to fund the development of our modern Afghanistan,onacriticalcaretransportmission. S384 *2012LippincottWilliams&Wilkins Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. JTraumaAcuteCareSurg Volume73,Number6,Supplement5 Blackbourneetal. Figure3. Timelineofmajormilitarymedicaladvancesinthepastdecade. This three-phase program includes an accredited para- we cannot apply the stringent scientific method needed to ad- medic program that will culminate in the National Registry of vancemanyoftheseareasandgainFDAapprovalfromstudies Emergency Medical Technicians (EMTs) paramedic examina- onthebattlefield.86 tion and critical care training. This 9-month training program The challengegoing forward will be to maintain the mo- will prepare the candidates to pass the Flight Paramedic Cer- tivation and momentum to complete the evolving and nascent tificationexaminationandtodeployoverseas,wheretheywill RMMAsandtoreceiveFDAapprovalfornewinnovationssothat beexpectedtoprovidecareforthefullspectrumofcasualties wecandeploythesenewcapabilitiesand,thus,optimizethecare being evacuated by helicopter. The role of critical care flight ofcombatwoundedinfutureconflicts. paramedicsorotheradvancedmedicalprovidersinTACEVAC platforms has also been endorsed by the DHB (DHB TACE- VACmemo). AUTHORSHIP L.H.B.wasresponsiblefortheconceptanddesignofthisarticle,com CONCLUSION pilation of the text, figure and table composition, and extensive reviews.Allauthorslistedcontributedasection,withreferences,intheir Fromahistoricalstandpoint,themedicalcareadvancesin areaofexpertiseandreviewedthearticle.Inaddition,D.G.B.andB.J.E. providedextensivereviewsofthearticle. combat casualty care during the past decade have been monu- mental(Fig.3).AsDr.Churchillinsightfullynotedmorethan ahalfacenturyago,mostofthecombatevidenceisretrospective ACKNOWLEDGMENTS observational data: ‘‘Cobwebs of theory and hypothesis were WethankMs.OtiliaSa´nchezfortheexperteditorialsupportandto swept away by simple observation and precise definitions,’’ for Mr.GlenGuellerfortheexpertgraphicssupport. *2012LippincottWilliams&Wilkins S385 Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. JTraumaAcuteCareSurg Blackbourneetal. 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S386 *2012LippincottWilliams&Wilkins Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

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