Prehospital Interventions During Mass-Casualty Events in Afghanistan: A Case Analysis

Schauer, Steven G; April, Michael D.; Simon, Erica; Maddry, Joseph K.; Robert, Caroline; Lorenzo, Robert A. De

doi:10.1017/s1049023x17006422

Cited by 9 publications

(7 citation statements)

References 10 publications

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“…Prognostication is important not only to optimize care for each individual patient, but also to inform planning and resource utilization in the event of mass-casualty incidents. 3 Existing literature has attempted to correlate multiple patient factors or initial variables with trauma patient outcomes. Much of this literature focuses on injury patterns and severity as measured by the injury severity score (ISS).…”

Section: Introductionmentioning

confidence: 99%

Early Vital Sign Thresholds Associated with 24-Hour Mortality among Trauma Patients: A Trauma Quality Improvement Program (TQIP) Study

April,

Fisher,

Rizzo

et al. 2024

Prehosp. Disaster med.

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Background: Identifying patients at imminent risk of death is critical in the management of trauma patients. This study measures the vital sign thresholds associated with death among trauma patients. Methods: This study included data from patients ≥15 years of age in the American College of Surgeons Trauma Quality Improvement Program (TQIP) database. Patients with vital signs of zero were excluded. Documented prehospital and emergency department (ED) vital signs included systolic pressure, heart rate, respiratory rate, and calculated shock index (SI). The area under the receiver operator curves (AUROC) was used to assess the accuracy of these variables for predicting 24-hour survival. Optimal thresholds to predict mortality were identified using Youden’s Index, 90% specificity, and 90% sensitivity. Additional analyses examined patients 70+ years of age. Results: There were 1,439,221 subjects in the 2019-2020 datasets that met inclusion for this analysis with <0.1% (10,270) who died within 24 hours. The optimal threshold for prehospital systolic pressure was 110, pulse rate was 110, SI was 0.9, and respiratory rate was 15. The optimal threshold for the ED systolic was 112, pulse rate was 107, SI was 0.9, and respiratory rate was 21. Among the elderly sub-analysis, the optimal threshold for prehospital systolic was 116, pulse rate was 100, SI was 0.8, and respiratory rate was 21. The optimal threshold for ED systolic was 121, pulse rate was 95, SI was 0.8, and respiratory rate was 0.8. Conclusions: Systolic blood pressure (SBP) and SI offered the best predictor of mortality among trauma patients. The SBP values predictive of mortality were significantly higher than the traditional 90mmHg threshold. This dataset highlights the need for better methods to guide resuscitation as initial vital signs have limited accuracy in predicting subsequent mortality.

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Section: Introductionmentioning

confidence: 99%

Early Vital Sign Thresholds Associated with 24-Hour Mortality among Trauma Patients: A Trauma Quality Improvement Program (TQIP) Study

April,

Fisher,

Rizzo

et al. 2024

Prehosp. Disaster med.

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“…Hemorrhage is the leading cause of potentially preventable death in both civilian and combat military settings 1,2 . The first step in casualty care is hemorrhage control through tourniquets, pressure dressings with hemostatic agents such as Combat Gauze (pro‐coagulant impregnated gauze), or pharmacologic intervention such as tranexamic acid (TXA) 3–9 . The next step is restoration of blood volume.…”

Section: Introductionmentioning

confidence: 99%

“…1,2 The first step in casualty care is hemorrhage control through tourniquets, pressure dressings with hemostatic agents such as Combat Gauze (pro-coagulant impregnated gauze), or pharmacologic intervention such as tranexamic acid (TXA). [3][4][5][6][7][8][9] The next step is restoration of blood volume. Use of crystalloid and colloid to replace lost blood lowers survival due to dilution of clotting factors and hemoglobin and worsening of acidosis.…”

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confidence: 99%

A prospective assessment of the time required to obtain one unit of fresh whole blood by civilian phlebotomists and Army laboratory technicians (68 K)

et al. 2023

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Background Resuscitation with blood products improves survival after major hemorrhage. Blood product administration at or near the point‐of‐injury (POI) amplifies this benefit. Size, weight, and cold‐chain management challenges all limit the amount of blood medics can carry. Warm fresh whole blood (WFWB) transfusions from a pre‐screened donor within the unit represent an alternative source of blood at the POI. We measured the time required for civilian and Army technicians performing phlebotomy frequently to obtain one unit of blood to serve as a goal metric for combat medics being trained in this skill. Methods We gathered demographic and experience data along with proportion of first intravenous cannulation attempt success, time to blood flow initiated, and time to unit draw complete. Results We prospectively enrolled 12 civilian phlebotomy technicians and 10 Army laboratory technicians performing whole blood collections on 50 and 68 donors respectively. The mean time from setup to needle insertion was 3.7 min for civilians versus 4.2 min for Army technicians. The mean time from blood flowing to the bag being full was 10.7 min versus 8.4 min for civilians versus Army technicians respectively. The mean bag weights were 514 g versus 522 g. First‐pass intravenous cannulation success was 96% versus 98% respectively. Conclusions We found a high first intravenous cannulation attempt success among both the civilian and Army technicians. Medians times were <5 min to obtain venipuncture and <11 min to obtain one unit. These findings provide time‐based benchmarks for potential use during transfusion training among military medics.

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“…A major limitation is the amount of blood carried to the POI is based on: size, weight, and volume restrictions, and of course, the limited time outside of powered refrigeration. In future large‐scale combat operations (LSCO), conventional force‐on‐force combat will likely cause casualties to exceed the capacity of stored products 16–19 . Data from the conflicts in Iraq and Afghanistan highlight the potential for small numbers of casualties to require large amounts of blood product for resuscitation 20–25 .…”

Section: Introductionmentioning

confidence: 99%

“…In future large-scale combat operations (LSCO), conventional force-on-force combat will likely cause casualties to exceed the capacity of stored products. [16][17][18][19] Data from the conflicts in Iraq and Afghanistan highlight the potential for small numbers of casualties to require large amounts of blood product for resuscitation. [20][21][22][23][24][25] Hence, the need for WFWB transfusions is likely to increase in the future.…”

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confidence: 99%

A prospective assessment of the medic autologous blood transfusion skills for field transfusion preparation

et al. 2023

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Background Data demonstrate the benefit of blood product administration near point‐of‐injury (POI). Fresh whole blood transfusion from a pre‐screened donor provides a source of blood at the POI when resources are constrained. We captured transfusion skills data for medics performing autologous blood transfusion training. Methods We conducted a prospective, observational study of medics with varying levels of experience. Inexperienced medics were those with minimal or no reported experience learning the autologous transfusion procedures, versus reported experience among special operations medics. When available, medics were debriefed after the procedure for qualitative feedback. We followed them for up to 7 days for adverse events. Results The median number of attempts for inexperienced and experienced medics was 1 versus 1 (interquartile range 1–1 for both, p = .260). The inexperienced medics had a slower median time to needle venipuncture access for the donation of 7.3 versus 1.5 min, needle removal after clamping time of 0.3 versus 0.2 min, time to bag preparation of 1.9 versus 1.0 min, time to IV access for reinfusion of 6.0 versus 3.0 min, time to transfusion completion of 17.3 versus 11.0 min, and time to IV removal of 0.9 versus 0.3 min (all p < .05). We noted one administrative safety event in which an allogeneic transfusion occurred. No major adverse events occurred. Qualitative data saturated around the need for quarterly training. Conclusions Inexperienced medics have longer procedure times when training autologous whole blood transfusion skills. This data will help establish training measures of performance for skills optimization when learning this procedure.

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Prehospital Interventions During Mass-Casualty Events in Afghanistan: A Case Analysis

Cited by 9 publications

References 10 publications

Early Vital Sign Thresholds Associated with 24-Hour Mortality among Trauma Patients: A Trauma Quality Improvement Program (TQIP) Study

Early Vital Sign Thresholds Associated with 24-Hour Mortality among Trauma Patients: A Trauma Quality Improvement Program (TQIP) Study

A prospective assessment of the time required to obtain one unit of fresh whole blood by civilian phlebotomists and Army laboratory technicians (68 K)

A prospective assessment of the medic autologous blood transfusion skills for field transfusion preparation

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