cdr john p wei, usn mc md 4th medical battalion, 4th mlg bsrf-12 and iraq trauma lessons from the...
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CDR JOHN P WEI, USN MC MD4th Medical Battalion, 4th MLG
BSRF-12
TRAUMA LESSONS FROM THE BATTLEFIELDS OF
AFGHANISTAN AND IRAQ AND IRAQ
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BATTLEFIELD TRAUMA
• Changes in epidemiology of combat injuries in current military conflicts
• Lessons learned from care of trauma victims in Afghanistan and Iraq
• Transfer relevant lessons to civilian medical practice
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31%31%
7%7%
5%5%
25%25% 10%10% 9%9%
12%12%
1 %1 %
KIA : CNS injuryKIA : CNS injury
KIA : Airway obstructionKIA : Airway obstruction
KIA : Blast / mutilating KIA : Blast / mutilating traumatrauma
KIA : Tension PTXKIA : Tension PTX
KIA : Torso trauma, not KIA : Torso trauma, not correctablecorrectable
KIA : Torso trauma, KIA : Torso trauma, correctablecorrectable
KIA : Extremity KIA : Extremity exsanguinationexsanguination
DOW : Infection, shock DOW : Infection, shock complicationscomplications
Causes of Death in Causes of Death in Ground CombatGround Combat
(KIA = Killed in Action ; DOW =
Died of Wounds)
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31%31%
7%7%
5%5%
25%25% 10%10% 9%9%
12%12%11%%
KIA: CNS injuryKIA: CNS injury
KIA: Airway obstructionKIA: Airway obstruction
KIA: Blast / mutilating KIA: Blast / mutilating traumatrauma
KIA: Tension PTXKIA: Tension PTX
KIA: Torso trauma, not KIA: Torso trauma, not correctablecorrectable
KIA: Torso trauma, KIA: Torso trauma, correctablecorrectable
KIA: Extremity KIA: Extremity exsanguinationexsanguination
DOW: Infection, shock DOW: Infection, shock complicationscomplications
Causes of Death in Causes of Death in Ground CombatGround Combat
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Location of Death for Fatally Location of Death for Fatally WoundedWounded
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Routine Use of Individual Body Armor (IBA) by the U.S. Military
Current issued U.S. Army IBA
Neck, shoulder, and groin flaps
Use of IBA accounts for the decrease in torso wounds and the increase in the percentage of extremity wounds
Use of polycarbonate protective eyewear
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CARE FOR INJURIES IN BODY ARMOR
With no skin penetration, internal injuries can occur from a bullet striking armor
• If hit on chest : lung contusion, rib fracture possible keep patient under observation, repeat chest x-ray at 4 to 6 hours
• If lower chest or abdomen hit : may be spleen or liver contusion or laceration
Kevlar armor impossible to cut with standard trauma scissors
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LIFE SAVING FIELD INTERVENTIONS
• Stop external hemorrhage• Extremity tourniquets safe and effective
• Needle decompression of tension pneumothorax in dyspneic patient
• Provide airway in unconscious patient• Nasopharyngeal or oral airway efficacious
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CPR ON BATTLEFIELD
• Utility of CPR in field:Utility of CPR in field:• drowningdrowning• hypothermiahypothermia• electrical shockelectrical shock• No benefit with mass casualties No benefit with mass casualties
involving limited resourcesinvolving limited resources
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PRIORITIES OF TRAUMA
• Life > priority over sight> limb• Exsanguinating hemorrhage >
priority over airway• Torso injury > priority over limb• Pulseless limb > priority over limb
with pulse• Open fracture > priority over closed
fracture
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MEDICAL LESSONS FROM BATTLEFIELD
• Clinical experience in dealing with blast and explosive injuries
• New strategies in treating hemorrhage• Mortality rates lower for the current
conflicts• Survivors of massive multiple trauma
with major deficits
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PRIOR U.S. MILITARY MEDICAL EXPERIENCE
Mortality Rates After Wounding :• Revolutionary War : 42 %• World War II : 30 %• Korean War : ~25 %• Vietnam War : ~25 %• Persian Gulf War : ~25 %• Iraq and Afghanistan: < 10 %
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CURRENT U.S. MILITARY MEDICAL EXPERIENCE
Medical advances from current conflicts:• Treatment of primary and secondary
blast injury• Use of damage control surgery• Blood and activated clotting factors• Tourniquets• Hemostatic agents and dressings
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CASUALTIES FROM IED (Improvised Explosive Devices)
• Predominance of current injuries in Afghanistan
• Severe, multisystem• Multiple limb amputations• Secondary injury from being thrown • Eardrum rupture• Occult injuries: blast lung, bowel rupture,
traumatic head injury
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IED BLAST INJURIES
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BLAST INJURY MECHANISMS
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CATEGORIES OF BLAST INJURIES
• Primary : blast pressure on organs and tissue
• Secondary : injuries from projectiles • Tertiary : blunt trauma from patient
thrown against hard object• Miscellaneous : burns, crush, toxic
inhalations
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POTENTIAL INJURIES IN BLAST VICTIM
• Respiratory• Pulmonary hemorrhage• Alveolar-venous fistula air embolism
production• Airway epithelial damage
• Circulatory • Cardiac contusion• Air embolism myocardial ischemia
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BLAST LUNG
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POTENTIAL INJURIES IN BLAST VICTIM
• Digestive tract• Gastrointestinal hemorrhage or
perforation• Retroperitoneal hemorrhage• Ruptured spleen or liver
• Eye and Orbit• Retinal air embolism• Orbital fracture
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POTENTIAL INJURIES IN BLAST VICTIM
• Auditory system• Tympanic membrane rupture• Ossicular fractures• Cochlear damage
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POTENTIAL INJURIES IN BLAST VICTIM
• Perform ear exam • If TM rupture obtain chest x-ray, hold
for 8 hour observation• If TM not ruptured, no other symptoms
conditionally exclude other serious primary blast injury
• Pulse oximetry : O2 saturation signals early blast lung before symptoms develop
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DAMAGE CONTROL SURGERY
Technique widely used in theaterCentral tenet: avoid “ The Deadly Triad”
• Hypothermia• Coagulopathy• Metabolic acidosis
Mortality and morbidity increases with additional risk factors
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DAMAGE CONTROL SURGERY
• Stop the bleeding• Close gastrointestinal leaks• Remove major contaminants• Leave wound open to avoid abdominal
compartment syndrome • Transfer to Intensive Care Unit (ICU)
for further stabilization and resuscitation
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DAMAGE CONTROL SURGERY
• Resuscitate in ICU
• Normalize blood pressure
• Normalize body temperature
• Normalize coagulation factors• Return to Operating Room when stable for
definitive surgery
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HEMOSTASIS
• International Normalized Ratio (INR) > 1.5 on arrival is predictive of need for massive transfusion
• Thawed fresh frozen plasma (FFP) is best resuscitation fluid in MT
• Optimum ratio of plasma : crystalloid is 1:1 to avoid clotting factor dilution > 50 %
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HEMOSTASIS
• Limit crystalloid use in the field :• Overuse can lead to inflammatory, acidotic,
coagulopathy effects
• Hextend (hetastarch) suitable for field use• give 500 cc, repeat once if hemorrhage
• Use fresh whole blood; not available, use one unit of FFP for each unit of banked packed cells
• Early use of cryoprecipitate• Recombinant Factor VIIa (rFVlla)• TXA (transamenic acid) for coagulopathy
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HEMOSTASIS
• Tourniquets :• Use for any significant extremity
hemorrhage• No adverse events seen • Use early• Issued to every soldier
• The Combat Application Tourniquet (CAT) can be applied by an injured soldier to himself using only one hand
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COMBAT APPLICATION TOURNIQUET
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HEMOSTASIS
• Hemostatic dressings :• Avoid coagulopathy : control bleeding
early• Used for non-extremity hemorrhage, but
also in severely mangled limbs• Apply with pressure < 5 minutes, patient
stabilized and evacuated
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HEMOSTASIS
• HemCon (chitosan)• Originally as bandage
• Now in roll that can be stuffed into wound• QuikClot (initially available as a powder ;
subsequently marketed in a adherent package)• Very exothermic (up to 147 o F)
• Difficult to debride from wound due to adherence• New Advanced Clotting Sponge (ACS)
• Gauze sack : is easily removed from wound
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MEDICATIONS IN FIELD• Medical providers carry oral antibiotics
(gatifloxacin 400 mg per day currently used) and pain meds (Celebrex 200 mg per day and / or acetominophen)
• Cefotetan 2 grams IV or IM for severely injured
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SUMMARY• Body armor has changed injury patterns• Tourniquets are lifesaving for exsanguinating
extremity wounds• Early antibiotics in the field are indicated• Fresh whole blood and plasma are best
resuscitation fluids• Damage control surgery is effective for the
massively injured• Blast victims have multiple, occult, and delayed
injuries