Wednesday, February 13, 2008

10 Advancements in Trauma, Tactical, and Battlefield Medicine

I enjoyed an excellent Grand Rounds lecture by Frank K. Butler, Jr., M.D. CAPT MC USN (RET), Medical Consultant for Naval Operational Medicine Institute in Pensacola, FL entitled “Tactical Combat Casualty Care: Update 2008.” Dr. Bulter outlines a number of advancements in trauma care which the military has been implementing and showcased the outstanding survivability data as a direct result of these developments.

There are some injuries for which nothing can be done on the battle field. Soldiers stuck in the head or through the heart cannot be saved. Unfortunately, a great percentage of soldiers die from injuries that could easily be saved with minimal resources and training. But new revolutionary advancements in Trauma and Tactical Medicine during the Afghanistan and Iraq wars have demonstrated significants improvements in survivability on the battle field over the past 50 years.

Mortality of Injured: WW2: 30%, Vietnam: 20%, Iraq 10%.

1. Tourniquets: Used to stop large arterial extremity bleeding as a last resort after direct pressure bandages. New designs can be easily placed with only one hand by the injured person.
2. Clotting Agents: HemCon and Quick Clot can be poured or packed into deep puncture wounds to stop bleeding.
3. Interosseous Access (IO): Using a small drill and cutting catheter, a line can be placed quickly into the sternum or tibia. Fluids, blood, antibiotics, and pain medicine can all be given through the IO line into the bone itself. IO lines have demonstrated very low rate of infection and are much less prone to failing like typical IVs.
4. Permissive Hypotension: In a bleeding patient, blood pressure should only be maintained to the point that consciousness is maintained. Resuscitating a patient to a normal blood pressure will blow newly formed clots off bleeding sites causing more severe bleeding.
5. Intravascular Volume Expanders: Traditional resuscitation fluids like NS and LR stay inside the vasculature for only 45 minutes before leaking out. Products like Hespan pull fluids into the blood vessels and stay in circulation for days. Also, medics aren't weighed down carrying heavy bags of IV fluids. Hespan does not carry oxygen so upcoming artificial blood products which do carry oxygen will be the exciting next development.
6. Oral Antibiotics: Moxifloxicin and other newly formulated antibiotics have 100% bioavailibility when taken orally as compared to IV dosing. An injured patient can easily receive antibiotics by mouth without needing a high maintenance IV. Using these antibiotics, wound infection rates have virtually evaporated to near zero.
7. Fentanyl Suckers: a powerful pain medicine sold under the trade name Actiq can easily and quickly be administered by mouth without using a high maintenance IV and removed if the patient becomes too sedated and experiences respiratory depression.
8. Fresh Frozen Plasma: Studies from Afghanistan and Iraq show that bleeding patients have better survival outcomes when given Fresh Frozen Plasma (FFP) in a 1:1 ratio with Packed Red Blood Cells (PRBCs).
9. Thorocostomy Needles: Gun shot wounds to the lung kill patients because air leaking out of the injured lung fills the chest until the pressure stops the heart from pumping blood. This is called cardiac tamponade resulting from a tension pneumothorax . This is easily prevented by inserting a needle and catheter into the chest wall allowing the trapped chest air to escape. Newer thoracostomy needles are longer and larger to facilitate this procedure on thick chested soldiers.
10. Advanced Airways: Many wounded soldiers who are knocked unconscious die simply because they suffocate on their own tongue. A simple chin lift or head tilt by another soldier is all that is needed many times to save a life until the soldier regains consciousness and can maintain his own airway. However, it can be very inefficient use of resources for a medic to hold open one airway while a handful of other wounded slowly bleed to death around him. So, new devices have been invented, tested, and successfully implemented which can be inserted into the airway and assist in respiration.


sonny said...

It is nice to see advances in trauma, beneficial hypotension for instance.
I did notice that you described pneumo/pneumohemothorax as "cardiac tamponade". Cardiac tamponade is the result of blood collecting between the pericardium and heart muscle preventing proper muscle contraction.

BRoz said...

You are correct that cardiac tamponade is a state of the heart in which the heart muscle can no longer maintain proper muscle contraction.

However, this state can be caused by several mechanisms. The cause of tamonade you speak of is called hemopericardium or pericardial effusion.

A pneumothorax which progresses to the degree that it is pushing on the heart and preventing normal muscle contraction is called a tension pneumothorax and is a common cause of cardiac tamponade.

Anonymous said...

All these advances seem like those simple, "why didn't I think of that"