Point-of-care ultrasound for treatment and triage in austere military environments

Abstract

BACKGROUND:Assessment and triage in an austere environment represent a major challenge in casualty care. Modern conflicts involve a significant proportion of multiple wounds, either superficial or penetrating, which complicate clinical evaluation. Furthermore, there is often poor accessibility to computed tomography scans and a limited number of surgical teams. Therefore, ultrasound (US) represents a potentially valuable tool for distinguishing superficial fragments or shrapnels from penetrating trauma requiring immediate damage-control surgery. METHODS:This retrospective observational multicenter study assessed casualties treated for 8 months by five medical teams deployed in Africa and Middle East. Two experts, who were experienced in military emergency medicine but did not take part in the missions, carried out an independent analysis for each case, evaluating the contribution of US to the following five items: triage categorization, diagnosis, clinical severity, prehospital therapeutic choices, and priority to operation room. Consensus was obtained using the Delphi method with three rounds. RESULTS:Of 325 casualties, 189 underwent US examination. The mean injury severity scale score was 25.6, and 76% were wounded by an improvised explosive device. Ultrasound was useful for confirming (23%) or excluding (63%) the suspected diagnosis made in the clinical assessment. It also helped obtain a diagnosis that had not been considered for 3% of casualties and was responsible for a major change in procedure or therapy in 4%. Ultrasound altered the surgical priority in 43% of cases. For 30% of cases, US permitted surgery to be temporarily delayed to prioritize another more urgent casualty. CONCLUSION:Ultrasound is a valuable tool for the management of mass casualties by improving treatment and triage, especially when surgical resources are limited. In some situations, US can also correct a diagnosis or improve prehospital therapeutic choices. Field medical teams should be trained to integrate US into their prehospital protocols.

Commentary on gaps in prehospital trauma care: education and bioengineering innovations to improve outcomes in hemorrhage and traumatic brain injury

“… 17 Evaluation of ultrasound in a combat setting found it changed therapy in 4% and altered the surgical priority in 43%, allowing a delay of surgery in 30% of wounded warfighters, improving overall triage accuracy. 18 Three-dimensional ultrasound employs volumetric imaging techniques to display a three-dimensional representation of internal structures, whereas four-dimensional or real-time three-dimensional ultrasound can show motion of the three-dimensional structures. 19 Commonly used in obstetrics and cardiovascular medicine, the panelists discussed how this technology provides better image quality, automated or computer-assisted image capture, processing, and identification of abnormal findings, advancing the field forward.…”

Role of Point-of-Care Diagnostics in Lower- and Middle-Income Countries and Austere Environments

“…As was discussed above regarding trauma and orthopedics, military clinicians are also able to conduct focused examinations and detect fractures with acceptable sensitivity and specificity. POCUS in the hands of trained military clinicians has the potential to improve diagnostic accuracy and ultimately improve care for the combatant and civilian casualty [27,28].…”

Role of point of care diagnostics in Lower-and Middle-income countries and austere environments

“…POCUS in the hands of trained military clinicians has the potential to improve diagnostic accuracy and ultimately improve care for the combatant and civilian casualty. [27,28] Ultrasound training It is imperative that training ultrasound usage needs to be incorporated into medical degree curriculums. The Toronto Addis Ababa Academic Collaboration in Emergency Medicine (TAAAC-EM) recently established an introductory POCUS rotation within the Emergency Medicine residency program at Addis Ababa University.…”