OpMed Journal Watch November 2019

Photo by Aaron Burden
Photo by Aaron Burden

This list of journal articles was collected via a Google Scholar watch list for new articles, citations, and related research of the following people: R Kotwal, A Fisher, J Kragh, M Schreiber, S Schauer, T Rasmussen, K Brohi, J Holcomb, R Mabry, B Eastridge, S Shackelford, F Butler.

Risk of Major Complications After Perioperative Norepinephrine Infusion Through Peripheral Intravenous Lines in a Multicenter Study

Risk of Major Complications After Perioperative Norepinephrine Infusion Through Peripheral Intravenous Lines in a Multicenter Study. Anesth Analg. 2019 Sep 27. doi: 10.1213/ANE.0000000000004445. [Epub ahead of print]

Results. A total of 14,385 patients who received norepinephrine peripheral continuous infusions were identified. Drug extravasation was observed in 5 patients (5/14,385 = 0.035%). There were zero related complications requiring surgical or medical intervention.
Conclusions. In the current database analysis, no significant association was found between the use of peripheral intravenous norepinephrine infusions and adverse events. See the take from REBEL EM.

Wilderness Medical Society Clinical Practice Guidelines for the Out-of-Hospital Evaluation and Treatment of Accidental Hypothermia: 2019 Update

Dow J, Giesbrecht GG, Danzl DF, Brugger H, Sagalyn EB, Walpoth B, Auerbach PA, McIntosh SE, et al. Wilderness Medical Society Clinical Practice Guidelines for the Out-of-Hospital Evaluation and Treatment of Accidental Hypothermia: 2019 Update. J Wild Environ Med. 2019. doi: https://doi.org/10.1016/j.wem.2019.10.002

To provide guidance to clinicians, the Wilderness Medical Society convened an expert panel to develop evidence-based guidelines for the out-of-hospital evaluation and treatment of victims of accidental hypothermia. The guidelines present the main diagnostic and therapeutic modalities and provide recommendations for the management of hypothermic patients. The panel graded the recommendations based on the quality of supporting evidence and a balance between benefits and risks/burdens according to the criteria published by the American College of Chest Physicians. The guidelines also provide suggested general approaches to the evaluation and treatment of accidental hypothermia that incorporate specific recommendations. This is the 2019 update of the Wilderness Medical Society Practice Guidelines for the Out-of-Hospital Evaluation and Treatment of Accidental Hypothermia: 2014 Update.

Every minute counts: The impact of pre-hospital response time and scene time on mortality of penetrating trauma patients

Ahmed A. H. Nasser, Charlie Nederpelt, Majed El Hechi, et al. The American Journal of Surgery. doi: 10.1016/j.amjsurg.2019.11.018

Highlights: Every minute increase in pre-hospital response time independently correlates with a 2% increase in mortality. Every minute increase in pre-hospital scene time independently correlates with a 1% increase in mortality. Scoop and run may be a more appropriate strategy for penetrating trauma patients.

A Consensus Framework for the Humanitarian Surgical Response to Armed Conflict in 21st Century Warfare

Sherry M. Wren, MD; Hannah B. Wild, BA; Jennifer Gurney, MD; et al. JAMA Surg. Published online November 13, 2019. doi: 10.1001/jamasurg.2019.4547

Key Points: Question  What are consensus components of a framework for humanitarian surgical response in modern conflict zones? Findings  This survey study using responses from 35 participants in the Stanford Humanitarian Surgical Response in Conflict Working Group suggests that humanitarian responses include both care of traumatic injury and emergency surgical needs of the population. Lessons from civilian and military trauma systems as well as humanitarian settings were translated into a tiered continuum of response from patient presentation through rehabilitation. Meaning  Evidence suggests that modern trauma systems save lives but providing this standard of care in insecure conflict settings places new burdens on humanitarian systems; the framework presented herein integrates advances in surgical care to these environments.

Austere Resuscitative and Surgical Care (ARSC) CPG ID: 76

Joint Trauma System Clinical Practice Guideline, 2019 (https://jts.amedd.army.mil/assets/docs/cpgs/Prehospital_En_Route_CPGs/Austere_Resuscitative_Surgical_Care_30_Oct_2019_ID76.pdf)


  • The intent of this Clinical Practice Guideline (CPG) is to provide guidance for Austere Resuscitative and Surgical Care (ARSC) teams, which are often comprised of conventional forces surgical units employed in support of special operations missions.
  • All ARSC teams should receive ARSC-specific, team-centric pre-deployment readiness training to include medical aspects and operational aspects of ARSC, with the result that ARSC teams are capable of protecting themselves and their patients and function well in a tactical environment.
  • The purpose of the ARSC team is to mitigate risk for the Operational Commander by providing surgical and resuscitative care for combat casualties. ARSC teams are smaller and more mobile compared to other conventional surgical assets and have less clinical capability and holding capacity. Realistic assessment of the risks and benefits of this capability must be clearly communicated to the Operational Commander.
  • Limited resources and staffing require that medical decisions are made in the context of the following variables: time and distance to the next role of care, capability of the next role of care, availability of blood products, sterility, anticipation of further casualties, evacuation capability, security, mobility, and patient holding capacity.
  • Patient care must focus on rapid triage, initial resuscitation with blood products, rapid control of hemorrhage and contamination with a damage control approach, and subsequent transfer to higher echelon.
  • Ultrasound of the chest and abdomen in patients with penetrating trauma to chest, abdomen, or pelvis or severe blunt trauma should be performed to rule out life threatening injuries.
  • A ruck-truck-house model, listed below, can help frame logistical considerations for planning purposes to maximize mobility and flexibility.
  • Documentation (e.g., JTS Austere Trauma Resuscitation Record, operative note) must be completed for all patients treated by ARSC teams and submitted to the JTS or uploaded into Theater Medical Data Store (TMDS).

Emerging Therapies for Prehospital Control of Hemorrhage

Mia K. Klein MD, Nick D. Tsihlis PhD, Timothy A. Pritts MD, PhD, Melina R. Kibbe MD. Journal of Surgical Research. doi: 10.1016/j.jss.2019.09.070

The aim of this review was to describe emerging therapies that could serve as a prehospital intervention to slow or stop noncompressible torso hemorrhage in the civilian and military settings. Hemorrhage accounts for 90% of potentially survivable military deaths and 30%-40% of trauma deaths. There is a great need to develop novel therapies to slow or stop noncompressible torso hemorrhage at the scene of the injury.

Results. Multiple potential therapies for noncompressible torso hemorrhage are currently under active investigation. These include (1) tamponade therapies, such as gas insufflation and polyurethane foam injection; (2) freeze-dried blood products and alternatives such as lyophilized platelets; (3) nanoscale injectable therapies such as polyethylene glycol nanospheres, polyethylenimine nanoparticles, SynthoPlate, and tissue factor–targeted nanofibers; and (4) other injectable therapies such as polySTAT and adenosine, lidocaine, and magnesium. Although each of these therapies shows great promise at slowing or stopping hemorrhage in animal models of noncompressible hemorrhage, further research is needed to ensure safety and efficacy in humans. Conclusions. Multiple novel therapies are currently under active investigation to slow or stop noncompressible torso hemorrhage in the prehospital setting and show promising results.

A Review of Whole Blood: Current Trauma Reports

Jared R. Gallaher, Martin A. Schreiber. Current Trauma Reports. December 2019, Volume 5, Issue 4, pp 210–215. (https://link.springer.com/article/10.1007/s40719-019-00178-2)

Interest in whole blood transfusion, particularly in trauma resuscitations, has been growing over the last decade. This has led to more data from civilian trauma centers on the efficacy of whole blood compared to component therapy, the safety profile, and the hemostatic effects of cold-storage.

Recent Findings. The summation of recent data suggests that whole blood is at least as effective as component therapy in trauma resuscitation although data is limited to relatively small volumes (< 6 units). The effect of leukoreduction on platelet function and other hemostatic markers appears to be small in vitro, but clinical data is lacking. There is virtually no data on massive resuscitation with whole blood (> 10 units) except for case reports. Summary. Resuscitation with whole blood appears to be safe and offers some advantages over component therapy. More clinical data is needed on the safety of whole blood in massive resuscitation and the potential hemostatic effects of whole blood transfusion.

Multiple organ dysfunction after trauma

E. Cole S. Gillespie P. Vulliamy K. Brohi on behalf of the Organ Dysfunction in Trauma (ORDIT) study collaborators. First published:06 November 2019 https://doi.org/10.1002/bjs.11361

The nature of multiple organ dysfunction syndrome (MODS) after traumatic injury is evolving as resuscitation practices advance and more patients survive their injuries to reach critical care. The aim of this study was to characterize contemporary MODS subtypes in trauma critical care at a population level.

Contemporary MODS has at least three distinct types based on patterns of severity and recovery. Further characterization of MODS subtypes and their underlying pathophysiology may lead to future opportunities for early stratification and targeted interventions.

Benefits and harms of increased inspiratory oxygen concentrations

Schwarte, Lothar A.; Schober, Patrick; Loer, Stephan A. Current Opinion in Anesthesiology: December 2019 – Volume 32 – Issue 6 – p 783-791doi: 10.1097/ACO.0000000000000791

The topic of perioperative hyperoxia remains controversial, with valid arguments on both the ‘pro’ and ‘con’ side. On the ‘pro’ side, the prevention of surgical site infections was a strong argument, leading to the recommendation of the use of hyperoxia in the guidelines of the Center for Disease Control and the WHO. On the ‘con’ side, the pathophysiology of hyperoxia has increasingly been acknowledged, in particular the pulmonary side effects and aggravation of ischaemia/reperfusion injuries.

Recent findings. Some ‘pro’ articles leading to the Center for Disease Control and WHO guidelines advocating perioperative hyperoxia have been retracted, and the recommendations were downgraded from ‘strong’ to ‘conditional’. At the same time, evidence that supports a tailored, more restrictive use of oxygen, for example, in patients with myocardial infarction or following cardiac arrest, is accumulating. Summary. The change in recommendation exemplifies that despite much work performed on the field of hyperoxia recently, evidence on either side of the argument remains weak. Outcome-based research is needed for reaching a definite recommendation.

Fresh Low Titer O Whole Blood Transfusion in the Austere Medical Environment

Alison Matthews MD, Steven G. SchauerDO, MS, Andrew D. Fisher MPAS, PA-C. Journal of Wilderness & Environmental Medicine. Volume 30, Issue 4, December 2019, Pages 425-430. doi: 10.1016/j.wem.2019.08.006

Massive hemorrhage is an immediate threat to life. The military developed the Tactical Combat Casualty Care guidelines to address the management of acute trauma, including administration of blood products. The guidelines have been expanded to include low titer O whole blood, which is in limited use by the military. This proposal describes how the transfusion of fresh whole blood might be applied to the remote civilian environment. In doing so, this life-saving intervention may be brought to the austere medical environment, allowing critically hemorrhaging patients to survive to reach definitive medical care.

Titrate to equilibrate and not exsanguinate! Characterization and validation of a novel partial resuscitative endovascular balloon occlusion of the aorta catheter in normal and hemorrhagic shock conditions

Forte, Dominic M. MD; Do, Woo S. MD; Weiss, Jessica B. MD, et al. Journal of Trauma and Acute Care Surgery: November 2019 – Volume 87 – Issue 5 – p 1015-1025. doi: 10.1097/TA.0000000000002378

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a significant advancement in the control of noncompressible truncal hemorrhage. However, its ischemic burden and reperfusion injury following balloon deflation limits its utilization. Partial restoration of aortic flow during REBOA has the potential to balance hemorrhage control and ischemia. This study validates the mechanics, physiology, and optimal partial flow rates using a prototype partial REBOA (pREBOA) device.

The pREBOA device demonstrated a high level of titratability for restoration of aortic flow. An optimal partial flow of 0.5 L/min was effective at hemorrhage control while limiting the burden of ischemic injury, and extending the tolerable duration of zone 1 occlusion. Aggressive calcium supplementation prior to and during partial occlusion and reperfusion may be warranted to prevent hyperkalemic arrest.

Cold-stored whole blood: A better method of trauma resuscitation?

Hazelton, Joshua Paul DO; Cannon, Jeremy W. MD; Zatorski, Catherine MD et al. Journal of Trauma and Acute Care Surgery: November 2019 – Volume 87 – Issue 5 – p 1035-1041 doi: 10.1097/TA.0000000000002471

Cold-stored whole blood (CWB) provides a balance of red blood cells, plasma, and platelets in less anticoagulant volume than standard blood component therapy (BCT). Cold-stored whole blood offers the benefit of a balanced resuscitation with improved trauma bay survival and higher mean hemoglobin at 24 hours. A larger, prospective study is needed to determine whether it has a longer-term survival benefit for severely injured patients.

Surgical care for conflict-related injuries among civilians in resource-limited settings

Andreas Älgå. From the Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden. https://openarchive.ki.se/xmlui/bitstream/handle/10616/46878/Thesis_Andreas_Alga.pdf

Armed conflicts significantly contribute to the global burden of injury and death. Armed conflicts shock health systems, deprive its resources and reduce its function, as well as limits access to civilian hospital care. In such resource-limited settings, the evidence on how to optimally manage the injuries sustained by civilians remains scarce.

Main Findings: Wound infection was associated with poor clinical outcomes and excess resource consumption. In addition, three out of four infected wounds contained multidrug-resistant bacteria. The main challenges in conflict wound management related to protocol adherence. Reasons for protocol deviations included resource scarcity, high patient loads, and limited compliance among patients and caregivers. Neither time to wound closure nor net clinical benefit was improved by NPWT compared to standard treatment for conflict-related extremity wounds. Treatment-related healthcare costs were higher for NPWT compared to standard treatment

Integrating Prolonged Field Care Into Rough Terrain and Mountain Warfare Training: The Mountain Critical Care Course

Benjamin Nicholson, MD, Jeremy Neskey, EMT-P, Ryan Stanfield, RN, BSN, CCRN, CEN, CFRN, Brandon Fetterolf, DO, James Ersando, SOCM-Paramedic, Jason Cohen, DO, Ricky Kue, MD, MPH. Journal of Special Operations Medicine. 2019;19(1). Pages 66-69. (https://pdfs.semanticscholar.org/6b26/c1ad1dc579be33193aff2c07190d023fa7ba.pdf)

Current prolonged field care (PFC) training routinely occurs in simulated physical locations that force providers to continue care until evacuation to definitive care, as based on the staged Ruck-Truck-House-Plane model. As PFC-capable teams move further forward into austere environments in support of the fight, they are in physical locations that do not fit this staged model and may require teams to execute their own casualty evacuation through rough terrain. The physical constraints that come specifically with austere, mountainous terrain can challenge PFC providers to initiate resuscitative interventions and challenge their ability to sustain these interventions during lengthy, dismounted movement over unimproved terrain. In this brief report, we describe our experience with a novel training course designed for PFC-capable medical teams to integrate their level of advanced resuscitative care within a mountainous, rough terrain evacuation-training program.

Our goals were to identify training gaps for Special Operations Forces medical units tasked to operate in a cold-weather, mountain environment with limited evacuation resources and the challenges related to maintaining PFC interventions during dismounted casualty movement.

An Analysis of Adherence to Tactical Combat Casualty Care Guidelines for the Administration of Tranexamic Acid

Andrew D. Fisher MPAS, PA-C, LP, Brandon M. Carius MPAS, PA-C, Michael D. April MD, PhD, Jason F. Naylor MPAS, PA-C, Joseph K. Maddry MD, Steven G. Schauer DO, MS. The Journal of Emergency Medicine. Volume 57, Issue 5, November 2019, Pages 646-652. doi:10.1016/j.jemermed.2019.08.027

Hemorrhage is the leading cause of potentially survivable deaths in combat. Previous research demonstrated that tranexamic acid (TXA) administration decreased mortality among casualties. Based on TCCC guidelines, we measured proportions of patients receiving prehospital TXA: casualties undergoing tourniquet placement, casualties sustaining amputation proximal to the phalanges, patients sustaining gunshot wounds, and patients receiving ≥10 units of blood products within 24 h of injury. Univariable and multivariable analyses were also completed.

Within our dataset, 255 subjects received TXA. Four thousand seventy-one subjects had a tourniquet placed, of whom 135 (3.3%) received prehospital TXA; 1899 subjects had an amputation proximal to the digit with 106 (5.6%) receiving prehospital TXA; and 6660 subjects had a gunshot wound with 88 (1.3%) receiving prehospital TXA. Of 4246 subjects who received ≥10 units of blood products within the first 24 h, 177 (4.2%) received prehospital TXA. We identified low TXA administration despite TCCC recommendations. Future studies should seek to both identify reasons for limited TXA administration and methods to increase future utilization.

Advanced Prehospital Trauma Resuscitation With a Physician and Certified Registered Nurse Anesthetist: The Shock Trauma “Go-Team”

William Howie DNP, CRNA, Mary Scott-Herring DNP, MS, CRNA, Andrew N. Pollak MD, Samuel M. Galvagno Jr. DO, PhD, FCCM. Air Medical Journal
Volume 39, Issue 1, January–February 2020, Pages 51-55. doi:10.1016/j.amj.2019.09.004

The R Adams Cowley Shock Trauma Center (STC) is Maryland’s primary adult resource center for trauma care. The Shock Trauma “Go-Team” is a specialized component of Maryland’s emergency medical system and is composed of a physician and certified registered nurse anesthetist. They are dispatched when advanced prehospital resuscitation is required. The purpose of this study is to describe the capabilities and historic epidemiology outcomes of the Go-Team. A retrospective case series review of recoverable Go-Team records was performed from 2011 to 2018.

The majority of deployments were via helicopter (73%) and lasted 2 hours. The most common indications for deployment were motor vehicle entrapment (41%), trench collapse (14%), and building collapse (9%). Of the 22 patients treated by the Go-Team, 50% received at least 1 blood transfusion in the field, and 23% required an advanced airway. No field amputations were required.

Safety of Pressurized Intraosseous Blood Infusion Strategies in a Swine Model of Hemorrhagic Shock

Jonathan D. Auten DO, Christian S. McEvoy MD, Paul J. Roszko MD. Journal of Surgical Research. Volume 246, February 2020, Pages 190-199. doi: 10.1016/j.jss.2019.09.005

Current guidelines support intraosseous access for trauma resuscitation when intravenous access is not readily available. However, safety of intraosseous blood transfusions with varying degrees of infusion pressure has not been previously characterized.

Swine were randomly assigned to proximal humerus intraosseous blood infusion with either Rapid Infuser, or Pressure Bag, or Push-Pull methods. Push-Pull conferred the highest flow rates, but with higher infusion pressures and evidence of intravascular hemolysis. Rapid Infuser and Pressure Bag infusions had no increase from baseline in plasma-free hemoglobin. Pressure Bag infusion was noted to confer an advantage in flow rates over Rapid Infuser. Intraosseous blood transfusion with pressure bags can safely bridge toward central access in the early phases of trauma resuscitation.


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