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«FINAL REPORT 30 January 2013 U.S. Central Command Pre-Hospital Trauma Care Assessment Team Russ S. Kotwal, MD MPH COL, MC, USA Director of Trauma ...»

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18-19 NOV 2012: Transportation: Ground travel from Camp As-Saliyah to Doha Airport, with follow-on air travel from Doha through Dubai to Washington Dulles via Boeing 777, Flight # 977.


Pre-Hospital Trauma Care:

1. In the US, trauma accounts for 42 million emergency department visits, 2 million hospital admissions, 172,000 deaths, and an economic burden of $406 billion in health care costs and lost productivity each year. Trauma is number one for the amount of life-years lost in the US, which is more than cancer, heart disease, and HIV combined. Trauma is the number one cause of death for those in the 1-44 age group; accounting for 47% of deaths. (Source: National Trauma Institute and Center for Disease Control) Trauma is the number one cause of death for active duty military. Trauma is the number one cause of death on the battlefield, and 87% of these battlefield deaths occur in the pre-hospital environment. Commensurate priority and funding should exist for trauma care training, equipment, research, and technologies, especially as it pertains to pre-hospital trauma care. (JTS Trauma Care Delivery Director)

2. Combatant unit commanders control the time, budget, personnel, training, and equipment for pre-hospital casualty response systems and trauma care. Thus, combatant unit commanders should own and be responsible for their casualty response systems. (Role I – 75th Ranger Regiment)

3. A review of the status of pre-hospital trauma care in combat theaters should be conducted on a regular basis to continue to look for opportunities to reduce preventable deaths among combat casualties. (JTS Director)

4. Throughout the course of hostilities in Afghanistan, TCCC has gone from being used by only a few USSOCOM and 18th Airborne Corps units to being used throughout the battle space. This evolution has, however, occurred unevenly and sporadically. (CENTCOM Surgeon)

5. There is incomplete fielding and use of updated TCCC technologies and techniques, even when these are desired by combatant units and endorsed by combatant unit medical leaders.

(Salerno Role I – 101st Airborne Division (Air Assault); Salerno Role I – DUSTOFF)

6. One reason for the apparent randomness of advances in pre-hospital trauma care is the lack of a clearly responsible organization for developing best-practice pre-hospital trauma care recommendations to the Services and Combatant Commanders. (CoTCCC Chairman)

7. A second reason for the apparent randomness of advances in pre-hospital trauma care is a matter of ownership, and the potential for decisions in this area to be made or not made by any number of different senior military leaders and at multiple levels within the chain of command of each service. (CoTCCC Chairman)

Unclassified Unclassified

8. Current deployed forces were aware of recent TCCC updates. This was due in large part to the efforts of the JTTS Deployed Director. This effort required a large amount of her available time. (JTTS Deployed Director) A JTTS Pre-Hospital Care Director would prove most beneficial in theater. (JTS Director)

9. Modifications downgrading TCCC recommendations were made by some units to reflect their concerns about 68W medics administering IV medications such as analgesics (morphine, ketamine) and antibiotics (ertapenam). (BAF Role I – 1st Infantry Division) Medics should be trained and equipped to meet battlefield requirements. (JTS Trauma Care Delivery Director)

10. The current standard for pre-hospital trauma care delivery on the battlefield is TCCC. This standard is continuously reviewed and updated by a committee of world-renowned traumatologists; however, medical administrators impose restrictions on first responders and medics that limit their ability to fully provide TCCC to their buddies on the battlefield. (JTS Trauma Care Delivery Director)

11. A recent medical article [Harris M, Baba R, Nahouraii R, Gould P. Self-induced bleeding diathesis in soldiers at a FOB in South Eastern Afghanistan. Military Medicine 2012;

177:928-9] showed that approximately 75% of troops at a Forward Operating Base (FOB) in Southeastern Afghanistan were taking aspirin or NSAIDs and were likely to have a self-induced coagulopathy. This was confirmed to still be true by multiple units interviewed. (Role I – 1st Infantry Division, 3rd Infantry Division, 101st Airborne Division (AASLT), 173rd Airborne Brigade Combat Team, CJSOTF, 75th Ranger Regiment) Our troops are using lots of Motrin. (KAF Role I – 3rd Infantry Division) Almost everybody in this unit take Motrin. (Bastion Role I – USAF Combat Rescue Officer)

12. The current TCCC recommendation for fluid resuscitation before blood products become available is hypotensive resuscitation with Hextend. Permissive hypotension was used as far back as WWI (Cannon 1918), and Bickell showed that aggressive pre-hospital fluid resuscitation with crystalloids increased mortality compared to no pre-hospital fluids. (Theater Trauma Conference – Shadow DUSTOFF CRNA)

13. The use of large volume crystalloid IV fluid resuscitation for casualties in shock was not practiced by all but one of the units interviewed. Not providing large volume IV fluid crystalloid resuscitation is a long-standing principle of care in TCCC that is now being adopted widely in the civilian community as well. It was a point of emphasis by FORSCOM and TRADOC in the recent past.

14. Not one study has shown any survival benefit from pre-hospital resuscitation of patients in hemorrhagic shock with crystalloids. (Theater Trauma Conference – BAF Role III Trauma Surgeon)

15. If a black box warning exists to not use lactated ringers IV fluid in patients with metabolic acidosis, then why do some continue to use lactated ringers in trauma patients who have a propensity toward metabolic acidosis? (JTS Trauma Care Delivery Director) 16. “Tourniquets have been very successful. In Iraq, 5 years ago, I saw casualties come in in shock and dying from single extremity injuries without tourniquets. Here, we are seeing triple and quadruple amputees come in with tourniquets applied, awake and talking to us.” (KAF Role III – Neurosurgeon)

Unclassified Unclassified

17. Tourniquet training in some TCCC courses is to place them “high and tight” on the extremity regardless of where the wound is. (Role III – BAF, KAF, Bastion; Role I – 1st Infantry Division, 3rd Infantry Division, 1 MEF) A tourniquet was recently placed high on the bicep for an amputated finger. (Bastion Role I – USA) This application technique combined with prolonged tourniquet time has been associated with complications in at least two non-US casualties as noted in correspondence from the JTTS Deployed Director. Consider providing additional TCCC guidance on tourniquet placement. (Bastion Role I – USA) If a “high and tight” tourniquet is placed during care under fire, emphasize reassessment and repositioning at the earliest opportunity during tactical field care. (JTTS Deployed Director)

18. Successful prevention of hypothermia, and minimal base deficit upon arrival to an MTF, are good indicators of quality pre-hospital trauma care. (JTTS Deployed Director).

19. A combat zone is not the place to practice your skills - this is the Superbowl. The most skilled provider available should perform each procedure, i.e. a combat deployment is not a training environment. Anesthesia always intubates, general surgery always places chest tubes, etc. (KAF Role III – Surgeon)

20. Four recent casualties came in with surgical airways, with only one done correctly. Several were performed on casualties with GSW to head. More basic airway management techniques may be more appropriate for these casualties. The current TCCC emphasis on not performing surgical airways unless there is an observed airway obstruction should be reinforced. (KAF Role III – Surgeon)

21. Tranexamic acid (TXA) was developed decades ago in Japan. It binds to lysine sites on plasminogen. It is FDA-approved for oral use in women with menorrhagia. It is a safe medication; there is one case report of a 17 y/o girl who took 37 gms of TXA. The patient recovered after supportive care. The London HEMS service carries and uses TXA pre-hospital.

TXA may be the best intervention available for pre-hospital care of patients with junctional and truncal hemorrhage. (Theater Trauma Conference – V Corps Physician Assistant)

22. Improving outcomes in bleeding casualties is best accomplished by stopping the bleeding NOW, and that means equipping first responders with TXA. (Theater Trauma Conference – V Corps Command Surgeon)

23. Individual combatants are allowed to carry morphine autoinjectors in some units. Corpsmen and medics are not allowed to carry and give TXA in most units. There is more potential risk to the casualty from using an autoinjector of morphine than from giving TXA. (CoTCCC Chairman)

24. Take home points on POI trauma care: 1) get the Tourniquet on right; 2) humeral IO insertions can be difficult; and 3) use more ketamine. Doubt that TBI and eye injury are really contraindications to ketamine use. C-spine may not be able to be cleared if casualty received ketamine. (Theater Trauma Conference – KAF Role III Navy EM Physician)

25. The trauma survival rates for US and Coalition forces in Afghanistan are better than in any other country in the world at present. "Afghanistan is right now the best place in the world to be wounded." (Theater Trauma Conference – BG Juergen Brandenstein, ISAF Surgeon)

–  –  –

clinics? We fight as we train, thus we must train as we would fight. It is a matter of conditioning.

(JTS Trauma Care Delivery Director)

27. Given the increased rate of infections for those admitted to an ICU versus a Ward after trauma, hypovolemic shock likely plays a role along with trauma care. The care provided in the environment at POI through the time the casualty reaches a surgeon is not well characterized.

This needs to be evaluated to assess the various influences on infection and possible areas that could be modified to improve casualty care and subsequent outcomes. (Theater Trauma Conference – SAMMC Chief of Infectious Disease)

28. Systemic antibiotics should be given to combat casualties with open wounds as soon as possible. The TCCC recommendations for POI antibiotics are appropriate. (Theater Trauma Conference – SAMMC Chief of Infectious Disease)

29. Good and creative head wraps are being applied by Role I personnel for hemostasis. (Role III – KAF Neurosurgeon)

30. Flexible forward surgical teams should be provided for deliberate named combat operations. The need for the mobile surgical support will increase as fixed forward surgical teams are downsized. (Role I – 3rd Infantry Division)

31. The UK guidelines are the UK version of the U.S. Joint Trauma System Clinical Practice Guidelines. Recommended reading: Joint Doctrine Publication 4-03.1 Clinical Guidelines for

Operations which is produced by the UK Ministry of Defence and available at the following URL:


32. As junctional tourniquets are developed and applied at Role I, we need to be cognizant of coexisting pelvic fractures with subsequent consequences and potential complications resulting from junctional tourniquet application. (Bastion Role III – UK)

33. Mild TBI training is overemphasized during pre-deployment training - so much so that medics and first responders have an inappropriate view of the criticality of this injury; training in the administration of the MACE has been emphasized more than tourniquet training in some units. Mild TBI is also the primary reason for over-calling the urgency of evacuations. Mild TBI should be considered a Category C evacuation. (JTTS Deployed Director) There is little to no evidence demonstrating improved outcomes in casualties with isolated mild TBI as a result of first responder interventions in the tactical setting. (CoTCCC Chairman)

34. The experience with ketamine as a battlefield analgesic has been very good to date.

(Salerno Role I – 101st; BAF Role I – CJSOTF, BAF Role I – Shadow DUSTOFF, Tarin Kowt Role I - NSW) Ketamine does not cause cardiorespiratory depression as opioids do and is, therefore, well-suited for casualties in pain who are also in shock or at risk for going into shock.

(CoTCCC Chairman) From August 2011 to August 2012, the DoD Trauma Registry recorded 93 administrations of ketamine to combat casualties in the pre-hospital battlefield environment with no complications noted. (JTS Trauma Care Delivery Director)

35. Experience by Role I providers with OTFC has been good. Casualties must be directed NOT to chew them, especially Afghan casualties. (BAF Role I – CJSOTF) Oral mucosa absorption accounts for half of the total absorbed dose and is responsible for OTFC’s rapid onset. [Kotwal RS, O’Connor KC, Johnson TR, Mosely DS, Meyer DE, Holcomb JB. A

–  –  –

novel pain management strategy for combat casualty care. Annals of Emergency Medicine 2004; 44(2): 121-7]

36. Loss of consciousness in the absence of airway obstruction is not an indication for a surgical airway. TCCC should clarify this point in the airway algorithm. (BAF Role I – CJSOTF)

37. Ground medics need to know to fill cricothyroidotomy or ET tube cuffs with saline for air evacuation; otherwise the inflated cuffs will expand at altitude. This has been a problem seven times in the recent past. (BAF Role I – USAF Senior PJ)

38. The two main causes of preventable death in the conflicts in Afghanistan and Iraq are noncompressible torso hemorrhage and junctional hemorrhage. [Eastridge BJ, Mabry RL, Seguin PG, et al. Death on the battlefield (2001-2011): implications for the future of combat casualty care. Journal of Trauma 2012, 73(6) Suppl 5: 431-7] Medics are asking for technologies and strategies to prevent death from these two causes. (Role I – 75th Ranger Regiment)

39. The TCCC battlefield analgesia options should be simplified. Consider reducing the prehospital pain management protocol to three treatment options: 1) Able to fight - Mobic and Tylenol, 2) Unable to fight and in no risk of shock – OTFC 800 mcg, 3) Unable to fight and in or at risk of shock – Ketamine 50 mg IM. (BAF Role I – CJSOTF; BAF Role I – 1st Infantry Division)

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