Article

Battlefield to bedside: Translating wartime innovations to civilian Emergency Medicine

Unlabelled imageAmerican Journal of Emergency Medicine 35 (2017) 1746-1749

Contents lists available at ScienceDirect

American Journal of Emergency Medicine

journal homepage:

Review

Battlefield to bedside: Translating wartime innovations to civilian Emergency Medicine

Melissa Givens, MD a, Andrew E. Muck, MD b,?, Craig Goolsby, MD c

a Uniformed Services University, Bethesda, MD, United States

b University of Texas Health Sciences Center at San Antonio, San Antonio, TX, United States

c Uniformed Services University, Bethesda, MD, United States

a r t i c l e i n f o

Article history:

Received 10 July 2017

Accepted 11 August 2017

(C) 2017

Introduction

The past 15 years of war in Afghanistan – Operation Enduring Free- dom (OEF) and Iraq – Operation Iraqi Freedom (OIF) has fostered nu- merous innovations in medicine. Combat casualty care has evolved out of necessity to ensure those injured in war have the best possible outcomes [1]. Significant advancements that saved lives on the battle- field are now being translated into civilian practice and public aware- ness at home. These advances hold special significance for Emergency Physicians (EPs) as the leaders in pre-hospital care and the initial phases of trauma resuscitation. Wartime, while unfortunate, accelerates inno- vation and research due to unprecedented number of trauma casualties and a military system which facilitates orderly processes and data col- lection. It is incumbent upon civilian practitioners and institutions to ex- plore these lessons learned in war for applicability in civilian practice and capitalize on wartime momentum of innovation. The following dis- cussion highlights techniques and procedures along with equipment and products that evolved as a result of the wartime experience which should be further explored in the academic realm to determine applica- bility for civilian Emergency Medicine (EM) practice.

Hemorrhage control“>Hemorrhage control

Mastering hemorrhage control, identified by Bellamy as the number one cause of Preventable death in the Vietnam War has proven to be the

* Corresponding author at: Department of Emergency Medicine, University of Texas Health Sciences Center at San Antonio, 7703 Floyd Curl Drive, MSC 7736, San Antonio, TX 78229, United States.

E-mail address: [email protected] (A.E. Muck).

harbinger of innovation in modern warfare [2]. The ability to collect wartime data, in of itself an innovation of the wars in Iraq and Afghan- istan, soundly turned the tide in regards to hemorrhage control. The Joint Theater Trauma System first demonstrated a need to control bat- tlefield hemorrhage, representing the majority of preventable deaths as previously described by Bellamy. Then the registry provided the data necessary to demonstrate hemorrhage control techniques and de- vices, such as the tourniquet, not only controlled bleeding, but also re- sulted in improved survival [3]. This data grew from changes in battlefield medicine encouraged by innovators such as Butler, who first described the concept of Tactical Combat Casualty Care (TCCC) and Kotwal, who championed an effort to make medical training a com- mand priority [4,5]. Such initiatives resulted in the far forward, pre-hos- pital focus on hemorrhage control by both medical and non-medical personnel and subsequently improved survivability.

Tourniquets

The quest for the best device for hemorrhage control is a timeless venture. Warfare in this century has been a mix of both positive and negative experiences with tourniquet use; from poor outcomes noted in World War I to more positive recollections of military surgeons dur- ing the Korean and Vietnam wars. Following WWI, Tuttle described rules for tourniquets that are still applicable today (Fig. 1) [6].

The wars of Iraq and Afghanistan set the stage for tourniquet use to evolve into an accepted paradigm. Early recognition of the need for hemorrhage control resulted in widespread use of tourniquets and the requisite data to confirm the impact of tourniquet use on survivability. Kragh et al. reported on 499 patients (862 tourniquets) with a survival rate of 87%. Despite liberal use of tourniquets, the morbidity was low

http://dx.doi.org/10.1016/j.ajem.2017.08.024 0735-6757/(C) 2017

M. Givens et al. / American Journal of Emergency Medicine 35 (2017) 17461749 1747

with b 2% occurrence of palsy at the level of the tourniquet, and a 0.4% incidence of limb shortening. The study finding underscored the impor- tance of early use of tourniquets with a survival rate of 96% when ap- plied before onset of shock and just 4% when applied after shock had ensued [7]. This pattern was observed again when looking at Tourniquet application among 232 patients seen at the combat hospital in Baghdad. Tourniquet use was strongly associated with saved lives and no limbs were lost due to tourniquet use [8].

Tourniquet use trickled from the battlefield into the civilian, even layperson, setting. Investigators in Boston were able to demonstrate ef- ficacy of tourniquets in a small study [9] and encouraged the use of pre- hospital tourniquets in systems that have the appropriate quality con- trol procedures. The Hartford Consensus emphasizes that bystanders are, “immediate responders,” and crucial to point-of-injury hemorrhage control, and Goolsby et al. demonstrated the ability of laypeople to apply tourniquets [10,11]. Currently there is an ongoing public cam- paign launched by the White House in 2015, Stop the Bleed (https:// www.dhs.gov/stopthebleed), which champions the use of tourniquets for civilian hemorrhage control.

Hemostatic agents

Because not all wounds are amenable to tourniquet application, the need for effective hemostatic dressings has also driven innovation while seeking to minimize blood loss from combat wounds. The early prod- ucts included powders or granules such as QuikClot to newer impreg- nated gauzes in a variety of configurations amenable to different wound characteristics. CoTCCC recommends Combat Gauze, a kaolin- ite-derived aluminosilicate nanoparticle infusion in traditional gauze, as its hemostatic dressing of choice. The CoTCCC also offer Celox, Chito gauze, and X-Stat as alternatives if Combat Gauze is not available [12]. While most of the data is confined to animal models, the Israeli Defense Force reported an 88.6% success rate in the control of junctional hemor- rhage [13].

The hemostatic dressings and products used in wartime are finding utility in civilian use not only in trauma patients but in a variety of bleeding issues which plague emergency physicians such as epistaxis, post-surgical bleeding, and lacerations [14]. There are multiple police and EMS vignettes that laud the use of hemostatic dressings to control bleeding in the tactical EMS setting.

Resuscitation

Modern combat trauma has provided the data necessary to explore optimal resuscitation. In civilian trauma only 2-3% of patients require massive transfusion protocols. Up to 8% of military trauma patients re- quires massive transfusions [15]. This disparity in transfusion require- ments makes the military a ripe venue to explore strategic approaches to resuscitation.

In some sense, trauma resuscitation had devolved since the first World War. The first use of preserved O- blood for transfusion was in 1917 by Captain Robertson from the United States Army Medical Of- ficer Reserves Corps. This evolved into the use of albumin and lyophi- lized (freeze-dried) plasma in combination with whole blood during

WWII. This practice was largely abandoned for component therapy dur- ing the Vietnam War and Initial resuscitation with crystalloid was the norm.

The mainstay of trauma resuscitation for Emergency Medicine pro- viders prior to the wars in Iraq and Afghanistan was based on the prin- ciples taught in Advanced Trauma Life Support (ATLS). This includes starting resuscitation with large-volume crystalloid infusion, followed by the addition of pRBCs and finally plasma. This approach in major ci- vilian trauma has demonstrated a greater incidence of abdominal com- partment syndrome, multiple organ failure and death compared to resuscitation with blood products [16]. Early efforts in the war tried to optimize the choice of crystalloid and/or colloid and have since leap- frogged into fine-tuning the delivery of the optimal blood product as close to the point of injury as possible. In addition, the Combat Fluid Re- suscitation Conference voiced the need for hypotensive resuscitation as early as 2001, foreshadowing evidence that supported this theory as an effective strategy to improve outcomes [17,18]. Since then, the CoTCCC has successfully implemented hypotensive resuscitation.

The authors’ personal experiences mirrored this transition from non-combat hospital based crystalloid fluid resuscitation to blood-prod- uct based hypotensive trauma resuscitation practice in combat settings. These changes in techniques kept military EPs at the cusp of trauma re- suscitation innovation.

Blood products

While fresh whole blood has been recognized as an ideal resuscita- tion tool, there was no mechanism in the combat theater for FDA ap- proval of either whole blood products or apheresis platelets. This resulted in the need to use a combination of blood products and efforts to optimize the ratio of available products to maximize outcomes.

Spinella et al. compared the use of warm fresh whole blood (WFWB) to component therapy in combat casualty patients from both Iraq and Afghanistan who were transfused with N 1 unit of RBCs. The patients who received WFWB got on average only 30% WFWB and 70% compo- nent therapy, however their survival rate was better than patients who had received component therapy alone [19].

The Combat Support Hospital in Baghdad, Iraq again provided the patient pool and data to look at the resuscitation variables associated with mortality. The study done by Borgman et al. is one of the first to explore Damage control resuscitation principles. This group of investiga- tors noted that in the 252 patients who received a massive transfusion, the higher the plasma ratio in the blood, the lower the risk of mortality and thus recommend plasma to RBC ratio of 1:1 for massive transfusion protocols [20]. Holcombe was able to reproduce these findings in a civil- ian population [21].

At the time of writing of this article, the 75th Ranger Regiment is conducting FWB collection at or near the point of injury in an effort to facilitate rapid initiation of transfusion in critically injured patients. This program involves extensive pre-screening in order to identify do- nors and ensure safe transfusion practices (E. Miles, MD, oral communi- cation, 28 March 2017). Lessons learned from this far forward collection and transfusion of FWB will be forthcoming and can be explored for ap- plicability in the most austere of civilian trauma setting.

Fig. 1. Rules for tourniquet use: handbook for the medical soldier (1927).

Tranexamic acid“>1748 M. Givens et al. / American Journal of Emergency Medicine 35 (2017) 17461749

Recognizing FWB or RBC: plasma component therapy is ideal, far for- ward Prehospital use of these resuscitation products is limited due to lo- gistical constraints. Freeze dried plasma (FDP) is an option in these circumstances. The use of freeze dried plasma is another concept that dates back to WWII. It is an attractive product for the military due to the stable shelf life (2 years) and no refrigeration requirement. Current- ly, there is no FDA approved FDP product available in the U.S. and the military has relied on French manufacturers and implemented an Inves- tigational New Drug (IND) application using French Lyophilized Plasma (FLYP). Far forward use of FLYP has been incorporated into Special Op- erations Forces protocols for pre-hospital resuscitation in addition to FDP use in Role II/III MTFs. Several other militaries from Norway, Israel, and Germany have experience with FDP in this context as well [22]. Ci- vilian pre-hospital use of FDP and PRBCs has successfully been demon- strated in Norway [23].

Tranexamic acid

Tranexamic acid has been suggested as a cheaper alternative to previously utilized Factor VII, and the CRASH-2 trial demonstrated a reduced the risk of death (OR 0.91 (0.85 to 0.97), P = 0.0035) and death from hemorrhage (0.85 (0.76 to 0.96), P b 0.001), without any in- crease in thromboembolic complications [24]. TXA has been incorporat- ed into the CoTCCC guidelines and is recommended in patients anticipated to need significant transfusion. Far forward medics are car- rying TXA and administering it nearly at the point of injury. The MAT- TERs study released in 2012 reported a lower mortality rate among combat casualty patients receiving TXA and component therapy com- pared to those who received component therapy alone despite higher injury severity scores [25].

TXA has not yet been largely inculcated into civilian trauma proto- cols [26]. While the military has embraced the prehospital use of TXA, the civilian sector continues to explore the best protocols and patient selection criteria for use within the hospital system.

Intraosseous devices

Not only was the choice of resuscitation improved throughout the wartime period, the mechanisms for delivery also significantly ad- vanced. Intravenous access had long been the mainstay of resusci- tation, but obtaining IV access in far forward austere conditions can be very challenging. Intraosseous (IO) infusion provided a viable alterna- tive. Doud described successful use of IO infusions for battlefield resus- citation in 1942 [27].A Military Medicine publication in 2000 revived the concept [28]. The military recommended that IO placement is a reason- able alternative when IV access is not attainable and preferred over a ve- nous cutdown. Industry quickly responded and developed IO devices to facilitate placement under harsh combat conditions by pre-hospital per- sonnel. Such devices included sternal insertion devices and electric drills that can be used to insert IO needles at various sites. The wide- spread use of IO devices in the military in both the prehospital and hos- pital setting has gained traction in the civilian community and is now a standard option for access in adult resuscitation [29].

Airway management

Cricothyroidotomy

airway compromise represents 1-2% of battlefield fatalities. While cricothyroidotomy is performed in b 0.4% of trauma patients in civilian settings, there is almost double that number reported in recent military experience [30]. While cricothyroidotomy is an infrequently performed procedure in either setting, it is a critical life-saving procedure. Due to the need to provide airway intervention in the most far forward circum- stances, the military has innovated training for combat medics to push this skill set as close to the point of injury as possible. The military has

experienced lower pre-hospital success rates than civilian reports (21% failure rate among combat medics and 15% among military physi- cians and physician assistants). However, the military has employed this procedure in medics only trained to the Emergency Medical Techni- cian – Basic level. Continued exploration of training methods and equip- ment that will improve cricothyroidotomy success are ongoing. Many of the current cricothyroidotomy kits and devices that facilitate and sim- plify the procedure can be attributed to the need to answer the military’s call for means to achieve more successful outcomes.

Pain management

Battlefield pain management involves all the nuances of pain man- agement encountered in the civilian hospital setting coupled with many other variables to include administration in the austere setting, devastating injuries, prolonged evacuation times, and the need to con- sider tactical awareness of the patient when circumstances dictate. Timely treatment of battlefield pain has even been linked to the chronic pain response and posttraumatic stress disorder . Morphine has long been the mainstay of battlefield pain control throughout this cen- tury of wartime conflict, but the wars in Iraq and Afghanistan saw the advance of morphine alternatives for the pre-hospital and hospital treatment of battlefield pain in the acute setting.

Oral transmucosal fentanyl citrate (OTFC)

Prior to Kotwal et al.’s published experiences using OTFC in Iraq, fen- tanyl use was primarily for cancer and chronic pain patients [31]. OTFC is a viable alternative to IV pain management in those patients with or- thopedic injuries or those with extremity wounds that would not other- wise have required IV access [32]. This novel approach greatly simplified pain control during transport, and allowed for titration in the tactical setting. Overtasked providers learned that taping the lolli- pop to the patient’s finger ensured the medication lollipop would fall out of the patient’s mouth and thus halt drug delivery when the patient became too sedated [31]. Military providers went on to demonstrate OTFC as a viable prehospital and austere setting pain management alter- native by demonstrating efficacy and safety in 286 patients who re- ceived OTFC in Iraq and Afghanistan. Only one major adverse event (hypoventilation) was noted in a patient who received high doses of fentanyl (3200 mcg) in addition to 20 mg of morphine [33].

Ketamine

There are many advantages to ketamine that proved useful in its ap- plication as a prehospital and austere pain control agent. At sub-disso- ciative doses, ketamine does not have the adverse hemodynamic effects or hypoventilatory effects of opioids, giving it an advantage for use in an austere setting with limited monitoring capability.

Military use of ketamine was gaining experience as the civilian liter- ature explored the efficacy and safety of ketamine use for sedation in the emergency department. The synergy of exploring it as a pain control agent by military medics and its use for airway management and proce- dural sedation in civilian settings resulted in a leap-frog of acceptance due to established safety in use [34,35]. The Army funded trials for the development of intranasal ketamine as a less invasive means of delivery [36,37]. Ketamine was added to the CoTCCC guidelines for analgesia in 2012 [38]. Civilian literature now reflects that ketamine is the anesthetic of choice in the prehospital setting when supplies of oxygen and moni- toring and disposable equipment are limited [39].

Conclusion

The wars in Iraq and Afghanistan led to breakthroughs in medical practice that have translated back to the civilian environment. As exam- ples, hemorrhage control, including the use of tourniquets and

M. Givens et al. / American Journal of Emergency Medicine 35 (2017) 17461749 1749

Hemostatic resuscitation, has been transformed, and intraosseous de- vices, used abundantly on the battlefield, are now commonplace in civil- ian medicine. We fully expect many additional military-to-civilian practice transfers to occur as war lessons are analyzed for our home en- vironments. It is critical for the military innovators to collaborate with civilian educators and researchers to translate lessons learned and iden- tify how to carry forward research initiatives relevant to civilian prac- tice. Progress achieved through the tragedy of lives lost and the victory of those saved should not be forgotten in the quiet interludes be- tween violent conflicts.

Acknowledgements

Lessons learned during war are often gained at the expense of in- jured individuals. Emergency Physicians who served honor the sacri- fices of others by pursuing the good that can be found amidst the loss. We offer our deepest appreciation for all those who have served.

References

  1. Blackbourne Lorne H, et al. Military medical revolution: Prehospital combat casualty care. J Trauma Acute Care Surg 2012;73(6):S372-7.
  2. Bellamy RF. The causes of death in conventional land warfare: implications for com- bat casualty care research. Mil Med 1984;149(2):55-62.
  3. Eastridge BJ, Costanzo G, Jenkins D, et al. Impact of joint theater trauma system initatives on battlefield injury outcomes. Am J Surg 2009;198(6):852-7.
  4. Butler Jr FK, Hagmann J, Butler EG. Tactical combat casualty care in special opera- tions. Mil Med 1996;161(suppl):3-16.
  5. Kotwal. Eliminating preventable deaths on the battlefield. Arch Surg 2011; 146(12):

    1350-58.

    Welling DR, McKay PL, Rasmussen TE, et al. A brief history of the tourniquet. J Vasc Surg 2012;455:286-90.

  6. Kragh JF, Littrel ML, Jones JA, et al. Battle casualty survival with emergency tourni- quet use to stop limb bleeding. J Emerg Med 2011;41(6):590-7.
  7. Kragh JF, Walters TJ, Baer DG, et al. Survival with emergency tourniquet use to stop bleeding in major limb trauma. Ann Surg 2009;249(1):1-7.
  8. Burke P, Kalish J, Feldman J, et al. original research evaluates the effectiveness of prehospital tourniquets for civilian penetrating injury. JEMS 2008;33(8).
  9. Goolsby C, Chen E, Branting A, Weissbrod E, David J, Moore K, et al. Analysis of lay- person tourniquet application using a novel color-coded device. Disaster Med Public Health Prep April 2016;10(2):274-80.
  10. Kellermann A, Mabry R. Bringing a battlefield lesson home. Acad Emerg Med 2015; 22(9):1093-5.
  11. Committee on Combat Tactical Casualt Care. TCCC Guidelines for Medical Personnel. through Journal of Special Operation Medicine https://www.jsomonline.org/TCCC/ TCCC%20Guidelines%20for%20Medical%20Personnel%20170131%20Final.pdf; 31

    January 2017, Accessed date: 9 April 2017.

    Ran Y, Hadad E, Daher S, et al. QuikClot combat gauze use for hemorrhage control in military trauma: January 2009 Israel defense force experience in the Gaza strip–a preliminary report of 14 cases. Prehosp Disaster Med 2010;25(6):584-8.

  12. Travers S, Lefort H, Ramdani E, et al. Hemostatic dressing in civil prehospital practice. Eur J Emerg Med 2015.
  13. Como JJ, Dutton RP, Scalea TM, Edelman BB, Hess JR. Blood transfusion rates in the care of acute trauma. Transfusion 2004;44:809-13.
  14. Balogh Z, McKinley BA, Cocanour CS, Kozar RA, Valdivia A, Sailors RM, et al. Supra- normal trauma resuscitation causes more cases of abdominal compartment syn- drome. Arch Surg 2003;138:637-43.
  15. Holcombe JB. Fluid resuscitation in modern combat casualty care: lessons learned from Somalia. J Trauma 2003;54:546-51.
  16. Morrison CA, Carrick MM, Norman MA, et al. Hypotensive resuscitation strategy re- duces Transfusion requirements and sever postoperative coagulopathy in trauma pa- tients with hemorrhagic shock: preliminary results of a randomized controlled trial. J Trauma 2011;70(3):652-63.
  17. Spinella PC. Warm fresh whole blood transfusion for severe hemorrhage: U.S. mili- tary and potential civilian applications. Crit Care Med 2008;36(7 Suppl):S340-5.
  18. Borgman MA, Spinella PC, Perkins JG, Grathwohl KW, Repine T, Beekley AC, et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma 2007;63:805-13.
  19. Holcomb JB, Wade CE, Michalek JE, Chisholm GB, Zarzabal LA, Schreiber MA, et al. In- creased plasma and platelet to red blood cell ratios improves outcome in 466 mas- sively transfused civilian trauma patients. Ann Surg 2008;248:447-58.
  20. Glassberg E, Nadler R, Gendler S, et al. Freeze dried plasma at the point of injury: from concept to doctrine. Shock 2013;40(6):444-50.
  21. Sunde GA, Vikenes B, Strandenes G, et al. Freeze dried plasma and fresh red blood cells for civilian prehospital hemorrhagic shock resuscitation. J Trauma Acute Care Surg 2015;78(6):S26-30.
  22. Roberts I, Shakur H, Coats T, et al. The CRASH-2 trial: a randomized controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlu- sive events and transfusion requirement in the bleeding trauma patient. Health Technol Assess 2013;17(10):1-79.
  23. Morrison JJ, Dubose JJ, Rasmussen TE. Military application of tranexamic acid in trau- ma emergency resuscitation (MATTERs) study. Arch Surg 2012;147(2):113-9.
  24. Napolitano LM, Cohen MJ, Cotton BA, et al. Tranexamic acid in trauma: how should we use it? J Trauma Acute Care Surg 2013;74(6):1575-86.
  25. Doud EA, Tysell JE. Massive intramedullary infusions. J Am Med Assoc 1942;120(15):

    1212-3.

    Dubick MA, Holcomb JB. A review of intraosseous vascular access: current status and military application. Mil Med 2000;165(7):552-9.

  26. Paxton JH. Intraosseous vascular access: a review. Dent Traumatol 2012;14(3): 195-232.
  27. Mabry RL, Frankfurt A. An analysis of battlefield cricothyroidotomy in Iraq and Af- ghanistan. JSOM 2012;12(1):17-23.
  28. Kotwal RS, O’Connor KC, Johnson TR, Mosely DS, Meyer DE, Holcomb JB. A novel pain Management strategy for combat casualty care. Ann Emerg Med 2004;44:121-7.
  29. Wedmore IS, Johnson T, Czarnik J, Hendrix S. Pain management in the wilderness and operational setting. Emerg Med Clin North Am 2005;23:585-601.
  30. Wedmore IS, Kotwal RS, McManus JG, et al. Safety and efficacy of oral transmucosal fentanyl citrate for prehospital pain control on the battlefield. J Trauma Acute Care Surg 2012;73(6 Suppl 5):S490-5.
  31. Green SM, Roback MG, Kennedy RM, Krauss B. Clinical practice guideline for emer- gency department ketamine dissociative sedation: 2011 update. Ann Emerg Med 2011;57(5):449-61.
  32. Guldner GT, Petinaux B, Clemens P, et al. Ketamine for procedural sedation and an- algesia by nonanesthesiologists in the field: a review for military health care pro- viders. Mil Med 2006;171(6):484-90.
  33. Black IH, McManus J. Pain management in current combat operations. Prehosp Emerg Care 2009;13:223-7.
  34. Christensen K, Rogers E, Green GA, et al. Safety and efficacy of intranasal ketamine for acute postoperative pain. Acute Pain 2007;9(4):183-92.
  35. US Defence Health Board. Pre hospital use of ketamine in battlefield analgesia in tac- tical combat casualty care pain guidelines; 2012 Mar.
  36. Kurdi MS, Theerth KA, Deva RS. Ketamine: current applications in anesthesia, pain, and critical care. Anesth Essays Res 2014;8(3):283-90.

Leave a Reply

Your email address will not be published. Required fields are marked *