Battlefield Casualties Treated at Camp Rhino, Afghanistan: Lessons Learned

Bilski, Tracy; Baker, Bruce C.; Grove, Jay R.; Hinks, Robert P.; Harrison, Michael J.; Sabra, John; Temerlin, Steven M.; Rhee, Peter

doi:10.1097/01.ta.0000046627.87250.1d

Cited by 82 publications

(40 citation statements)

References 5 publications

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“…Military evacuation timelines can differ significantly from those normally found in civilian settings. Although evacuation times in mature military operations are predominantly short, as are now being seen in Afghanistan, timelines in less mature settings (as we have seen recently [23,24]) can be considerably longer. Responsive resuscitation strategies such as the UK battlefield advanced trauma life support (BATLS [25]) are therefore needed to accommodate situations where evacuation timelines are extended and accounting for military injuries.…”

Section: Forward (Pre-hospital) Resuscitationmentioning

confidence: 99%

Blast injury research models

Kirkman

Watts

Cooper

2011

Phil. Trans. R. Soc. B

105

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Blast injuries are an increasing problem in both military and civilian practice. Primary blast injury to the lungs (blast lung) is found in a clinically significant proportion of casualties from explosions even in an open environment, and in a high proportion of severely injured casualties following explosions in confined spaces. Blast casualties also commonly suffer secondary and tertiary blast injuries resulting in significant blood loss. The presence of hypoxaemia owing to blast lung complicates the process of fluid resuscitation. Consequently, prolonged hypotensive resuscitation was found to be incompatible with survival after combined blast lung and haemorrhage. This article describes studies addressing new forward resuscitation strategies involving a hybrid blood pressure profile (initially hypotensive followed later by normotensive resuscitation) and the use of supplemental oxygen to increase survival and reduce physiological deterioration during prolonged resuscitation. Surprisingly, hypertonic saline dextran was found to be inferior to normal saline after combined blast injury and haemorrhage. New strategies have therefore been developed to address the needs of blast-injured casualties and are likely to be particularly useful under circumstances of enforced delayed evacuation to surgical care.

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Section: Forward (Pre-hospital) Resuscitationmentioning

confidence: 99%

Blast injury research models

Kirkman

Watts

Cooper

2011

Phil. Trans. R. Soc. B

105

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“…29 -31 Before the development of the formal combat trauma system, little data were being published about the conflict, and the data being published was largely small series and case reports. [32][33][34][35][36][37][38][39][40][41][42][43] With the thought that research drives doctrine, a concerted effort was put forth to field the JTTR. This registry is a concise form developed to capture demographic, mechanistic, physiologic, diagnostic, therapeutic, and outcome data along with a brief physical examination (Fig.…”

Section: Researchmentioning

confidence: 99%

Trauma System Development in a Theater of War: Experiences From Operation Iraqi Freedom and Operation Enduring Freedom

Eastridge

Jenkins

Flaherty

et al. 2006

The Journal of Trauma: Injury, Infection, and Critical Care

247

180

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“…We chose to target resuscitation endpoints in sBP because this is an easily obtainable measurement in the field and does not require additional calculation. We chose a period of 8 hours for hypotensive resuscitation because: 1) although current transport times in Iraq are shorter, previous experience in Afghanistan and Somalia has demonstrated delays in care of battlefield-wounded soldiers suffering from hemorrhagic shock due to battlefield conditions of up to 14 hours, 1,8 2) recent published data 9,10 and preliminary data from our laboratory suggest that longer hypotensive resuscitation time periods are more likely to reveal clinically relevant hemodynamic and metabolic changes, and 3) we wanted to identify a dose-response effect of different resuscitation endpoints on prolonged hypotensive resuscitation. We chose to use a controlled model of hemorrhagic shock to isolate the effects of prolonged hypotensive resuscitation on physiology without the confounding effects of rebleeding.…”

mentioning

confidence: 99%

“…However, the transport time for battlefieldwounded soldiers in Afghanistan, and to a lesser extent in Iraq, has allowed the implementation of early hypotensive resuscitation for hemorrhagic shock in those arenas. 1 The critical missing elements in the doctrine of early hypotensive resuscitation are how low and how long are safe? Little is known regarding the physiologic effects of prolonged hypotensive resuscitation.…”

mentioning

confidence: 99%

“…or battlefield-wounded soldiers with hemorrhagic shock in the United States Armed Forces, the current standard of care is initial hypotensive resuscitation to a weakly palpable radial artery pulse [1][2][3] that correlates to a systolic blood pressure (sBP) of 80 mm Hg. 4 In 1918, Cannon et al 5 initially proposed limiting fluid resuscitation for patients with hemorrhagic shock before controlling active bleeding: ''restoration of blood pressure prior to control of active bleeding may result in loss of blood that is sorely needed.''…”

mentioning

confidence: 99%

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Eight Hours of Hypotensive versus Normotensive Resuscitation in a Porcine Model of Controlled Hemorrhagic Shock

Skarda

Mulier

George

et al. 2008

Academic Emergency Medicine

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Objectives: The aim of this study was to compare hypotensive and normotensive resuscitation in a porcine model of hemorrhagic shock.Methods: This was a prospective, comparative, randomized survival study of controlled hemorrhagic shock using 28 male Yorkshire-Landrace pigs (15 to 25 kg). In 24 splenectomized pigs, the authors induced hemorrhagic shock to a systolic blood pressure (sBP) of 48 to 58 mm Hg (35% bleed). Pigs were randomized to undergo normotensive resuscitation (sBP of 90 mm Hg, n = 7), mild hypotensive resuscitation (sBP of 80 mm Hg, n = 7), severe hypotensive resuscitation (sBP of 65 mm Hg, n = 6), or no resuscitation (n = 4). The authors also included a sham group of animals that were instrumented and splenectomized, but that did not undergo hemorrhagic shock (n = 4). After the initial 8 hours of randomized pressure-targeted resuscitation, all animals were resuscitated to a sBP of 90 mm Hg for 16 hours.Results: Animals that underwent severe hypotensive resuscitation were less likely to survive, compared with animals that underwent normotensive resuscitation. Mean arterial pressure (MAP) decreased with hemorrhage and increased appropriately with pressure-targeted resuscitation. Base excess (BE) and tissue oxygen saturation (StO 2 ) decreased in all animals that underwent hemorrhagic shock. This decrease persisted only in animals that were pressure target resuscitated to a sBP of 65 mm Hg.Conclusions: In this model of controlled hemorrhagic shock, initial severe hypotensive pressuretargeted resuscitation for 8 hours was associated with an increased mortality rate and led to a persistent base deficit (BD) and to decreased StO 2 , suggesting persistent metabolic stress and tissue hypoxia. However, mild hypotensive resuscitation did not lead to a persistent BD or to decreased StO 2 , suggesting less metabolic stress and less tissue hypoxia.ACADEMIC EMERGENCY MEDICINE 2008; 15:845-852 ª

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Battlefield Casualties Treated at Camp Rhino, Afghanistan: Lessons Learned

Cited by 82 publications

References 5 publications

Blast injury research models

Blast injury research models

Trauma System Development in a Theater of War: Experiences From Operation Iraqi Freedom and Operation Enduring Freedom

Eight Hours of Hypotensive versus Normotensive Resuscitation in a Porcine Model of Controlled Hemorrhagic Shock

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