cord cunningham, md, mph lieutenant colonel, us army 1st ... · • explore the army implementation...

Cord Cunningham, MD, MPH Lieutenant Colonel, US Army

1st Air Cav Flight Surgeon EMS Physician

Salviens Vita, Serviens Bellatorum

• Opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the Department of the Army or the Depart-ment of Defense.

• No conflicts except my concern and drive to reduce prehospital/battlefield morbidity & mortality


• Deep dive into the clotting cascade

• An airway talk

• Stand alone or comprehensive solution/reference applicable in its entirety to every EMS/Trauma system


• Explore the Army implementation of Damage Control Resuscitation

• Understand The National Academy of Sciences recent Zero Preventable Trauma Deaths report and its implications to both military and civilian trauma systems

• Introduce the transition of the Army from Forward Surgical Teams to Forward Resuscitative Surgical Teams

• Discuss Military programs of Fresh Whole Blood transfusion, TXA, Freeze Dried Plasma, & REBOA and future concepts of prehospital DCR


• Prehospital DCR is important

• Lethal Triad understanding

• Aspects of DCR are applicable to civilian EMS


• About me • What is Damage Control Resuscitation(DCR) • DCR Importance • Zero Preventable Deaths • Hemorrhage Control • Lethal Triad • Ranger O-Low Titer • Massive Transfusion • Forward Resuscitative Surgical Team • Conclusion/Discussion


• Board Certified Emergency Physician

• 1 of 5 Active Army EMS Subspecialty Board Certified

• 5 Deployments to Iraq/Afghanistan with 75th Ranger Regiment & USSOCOM

• Medical Director of 15 Air Ambulance Unit and Fort Hood MSTC

• Involvement in many DoD Prehospital initiatives

CoERCCC, MHS Genesis, medical monitor FDP & USAISR CCC research


• Don’t get dead(create another cax)

• Make the blood go round & round

• Make the air go in and out

• Treat pain and ease suffering

• Hand off better than you found it


Damage control resuscitation comprises early hemorrhage control, hypotensive resuscitation (permissive hypotension), hemostatic(balanced) resuscitation(minimization of crystalloid fluids and fixed ratio blood product transfusion), prevention or alleviation of hypothermia (through warming measures), and amelioration of acidosis through judicious use of blood products and hemodynamic resuscitation endpoints.

Stopping hemorrhage and addressing the

lethal triad, reducing massive transfusion, improving survival.

Temporizing but critical

Presenter

Presentation Notes

Statistics and articles showing increased mortality with massive transfusion with coagulopathy at arrival to hospital

0500

100015002000250030003500400045005000

Pre-MTF Deaths MTF Deaths

3040

271

976

287

Potentially Survivable

Non-Survivable

Eastridge BJ, Mabry RL, Seguin PG, et al. Death on the battlefield (2001-2011): implications for the future of combat casualty care. Journal of Trauma, 2012. Eastridge BJ, Hardin M, Cantrell J, et al. Died of wounds on the battlefield: causation and implications for improving combat casualty care. Journal of Trauma, 2011. 71(Suppl 1):4-8.


• Overarching 11 rec paper • #1-White House set aim of zero • SECDEF holds COCOMs and

DHA accountable • ACS, NHTSA, & NAEMSO

collaboration with HHS/DoD • Focus on 1-2 big initiatives a yr • Develop and maintain expertise


• Surgeon General of UK Armed Forces

• Described cycle of improving trauma cax care during war and then losing that expertise inter war only to relearn it again

• Displayed in every US War from Civil War on

• Our challenge to avoid the “Dip”


• Zone 1-Extremity

• Zone 2-Junctional

• Zone 3-Truncal

Presenter

Presentation Notes

Zones of Hemorrhage: Defining Vascular Injury in Military Patients with Complex Pelvic Fractures a Consensus Panel Review 2013


• Immediate direct pressure and early hasty tourniquet (high & tight)

• Use of TQ prior to shock 90% improvement in survival vs after shock

• No permanent sequelae < 3hr and unlikely < 6hrs

• CATs on every FD/EMS/PD • Hartford Consensus “Stop the Bleed”


• SJT • CRoC • JETT • AAJT

Presenter

Presentation Notes

Kheirabadi, Bijan S., et al. "Physiological Consequences of Abdominal Aortic and Junctional Tourniquet (AAJT) Application to Control Hemorrhage in a Swine Model." Shock (Augusta, Ga.) (2016). All tourniquet uses were 100% effective for hemorrhage control. For blood loss, CRoC and SJT performed best with least blood loss and were significantly better than JETT; in pairwise comparison, CRoC-JETT (P < .0001) and SJT-JETT (P = .0085) were statistically significant in their mean difference, while CRoC-SJT (P = .35) was not. For time to hemostasis in pairwise comparison, the CRoC had a significantly shorter time compared to JETT and SJT (P < .0001, both comparisons); SJT-JETT was also significant (P = .0087). In responding to the directive, “Rank the performance of the models from best to worst,” users did not prefer junctional tourniquet models differently (P > .5, all models). ConclusionThe CRoC and SJT performed best in having least blood loss, CRoC performed best in having least time to hemostasis, and users did not differ in preference of model. Models of junctional tourniquet performed differentially by blood loss and time to hemostasis.


• Kaolin-inert clay type material promotes clotting • Chitosan-derived from crustacean shells and

promotes congealing of RBC/platelets independent of factors

• Mechanical/Expansive


• Considered not externally compressible(AAJT??)

• REBOA(ER-REBOA 7 fr) • Field Thoracotomy • Foam(testing) • Leads to lethal triad

Presenter

Presentation Notes

Kheirabadi, Bijan S., et al. "Physiological Consequences of Abdominal Aortic and Junctional Tourniquet (AAJT) Application to Control Hemorrhage in a Swine Model." Shock (Augusta, Ga.) (2016). Peev, Miroslav P., et al. "Self-expanding foam for prehospital treatment of severe intra-abdominal hemorrhage: dose finding study." Journal of Trauma and Acute Care Surgery 76.3 (2014): 619-624. Mesar, Tomaz, et al. "Human dose confirmation for self-expanding intra-abdominal foam: A translational, adaptive, multicenter trial in recently deceased human subjects." Journal of Trauma and Acute Care Surgery 79.1 (2015): 39-47. Summary cadaveric test to determine 65ml is appropriate volume to not exceed


J Trauma 2011


• Coagulopathy

• Acidosis

• Hypothermia


• Disruption/dilution/imbalance of some aspect of the clotting cascade

• Addressed prehospital via TXA, FDP, PRBCs, & FWB


• Antifibrinolytic by competitive inhibition at multiple plasminogen sites decreasing fibrin formation

• Cyclokapron IV FDA approved for dental procedure bleeding prophylaxis in hemophiliacs and bleeding post CABG


• CRASH-2 & MATTERs • < 1hr, 1-3hr, >3hr • No proven benefit in IC bleed • Administration

– Slow IV push 1 min(hypotension) – Filter needle(glass) – Potential for readministration


• Current-French product from pooled donors, glass bottle, reconstituted before administration

• Experimental protocol for DoD(USASOC) as part of FDA IND for French FDP

• US Army Medical Material Development Activity by 2020 US product(US plasma, plastic bag)

Presenter

Presentation Notes

Completed the IND in 23 days


• Carry of PRBC’s on MEDEVAC • Conventional use began in RC

South AFG in 2012(EMT) • Despite expansion still only in

CENTCOM • 1 u PRBC, 1 u FFP currently


• 5 KIA in 50 receiving PRBCs

• 75 KIA in 267 without

• Unadjusted p=.007


• May 2015 screening initiated • O type consented TTD and IgM • TTD – and IgM < 256 ID’d • Retested annually and counseled

on safe practices • Mar 2016 first txfn • 3 cases(4u’s) to date(predrawn) • Boundtree/Chinook sets draw

with 14/16ga and no Y line

Presenter

Presentation Notes

Application to Civilian?? TEMS, Austere, Maritime


• Prehospital shock index HR/SBP predicts massive transfusion(MT) (Vandromme et al., 2011)

• McLaughlin et al identified HR, SBP, pH, Hct as predictors of MT(HR > 105 OR 4.8)

• Use of the ABC(assessment blood consumption) score BP, HR, penetrating truncal injury and positive FAST to predict MT(Nunez et al) ABC ≥ 2 75% sens 86% sp

• PROMMTT Study(Holcomb et al) 3 u -1/1 • Transient prehospital hypotension but

normal in ED(Lipsky et al) 3 x • Are Red/Blue Major/Minor trauma criteria

enough to predict MT

Presenter

Presentation Notes

Del Junco, Deborah J., et al. "Resuscitate early with plasma and platelets or balance blood products gradually: findings from the Prospective, Observational, Multicenter, Major Trauma Transfusion (PROMMTT) Study." The journal of trauma and acute care surgery 75.1 0 1 (2013): S24. Lipsky, Ari M., et al. "Prehospital hypotension is a predictor of the need for an emergent, therapeutic operation in trauma patients with normal systolic blood pressure in the emergency department." Journal of Trauma and Acute Care Surgery 61.5 (2006): 1228-1233. Vandromme, Marianne J., et al. "Identifying risk for massive transfusion in the relatively normotensive patient: utility of the prehospital shock index." Journal of Trauma and Acute Care Surgery 70.2 (2011): 384-390. McLaughlin, Daniel F., et al. "A predictive model for massive transfusion in combat casualty patients." Journal of Trauma and Acute Care Surgery 64.2 (2008): S57-S63. Nunez, Timothy C., et al. "Early prediction of massive transfusion in trauma: simple as ABC (assessment of blood consumption)?." Journal of Trauma and Acute Care Surgery 66.2 (2009): 346-352. -Penetrating mechanism (0 no, 1 yes) ● ED SBP of 90 mm Hg or less (0 no, 1 yes) ● ED HR of 120 bpm or greater (0 no, 1 yes) ● Positive FAST (0 no, 1 yes)


• Metabolic cellular demand and waste production exceeds supply and CV carrying capacity(shock)

• Balanced fluid resuscitation, identification/monitoring, hypovolemia, hypoxemia, hypercarbia


• Tissue oxygenation

• ETCO2

• CRI

• VBG/Lactate/BE-


• Independent contributor to coagulopathy/increased metabolism

• Balanced with exposure for assessment and intervention

• Can occur even in hot environments (HPMK and vehicle heat)

FST 10 / 0 / 10 // 20

FRST 13 / 0 / 7 // 20

Medical Team, Forward Surgical Team (Current)

GR MOSLN NO O5 61J00 1 O4 61J00 2 O4 61M00 1 O4 66S00 1 O3 66E00-OR 1 O3 66F00 2 O3 66T00 1 O2 70B67 1 E7 68W40 1 E6 68D30 1 E5 68D20 1 E5 68C20 1 E5 68W20 1 E4 68D10 1 E4 68C10 2 E4 68W10 1 E3 68W10 1

Medical Team, Forward Resuscitative

and Surgical Team

GR MOSLN NO

O5 61J00-Surg 1 O4 61J00 1 O4 61M00-Ortho 2 O4 66S00-CCRN 1 O3 66S00 1 O3 66T00-ER RN 2 O3 66F00-CRNA 2 O3 62A00-EP 2 O2 70B67-MSC 1 E7 68W40-EMT 1 E6 68D30-OR 1 E5 68W20-EMT 2 E5 68C20-LPN 1 E5 68D20 1 E4 68C10 1

• Complete FRST, provides emergency treatment to receive, triage, and prepare 30 incoming casualties for surgery over a 72 hour period and postoperative care can manage 8 patients over 6 hours post-surgery.

• Two resuscitative and surgical elements, capable of supporting split based operations (10 personnel each), provide emergency treatment to receive, triage, and prepare 12 incoming casualties for surgery (each) over a 72 hour period, and postoperative care for 4 patients over 6 hours post surgery.

• Two surgical elements, capable of supporting very short duration (24 hours) operations, consisting of only a surgical element (6 personnel) provide emergency treatment to 4 incoming casualties for surgery and limited continued postoperative care for those critically wounded/injured patients over a period of 24 hours.


• Bleeding and airway control within 10 minutes

• Damage Control Resuscitation within 1 hour

• Aim to provide Damage Control Surgery within 1 hour but no later than 2 hours


What we dream of

What we might get

What we aim for

What we have now


• EMR/EMT/AEMT/NRP

• Minimum psychomotor skills

• EMT=NPA/OPA, PO Glucose/ASA

• 68W requires approx 212 hrs to AEMT

• 68W doing DCR!?


• Prehospital DCR is important

• Lethal Triad understanding(basic yet complex)

• Aspects of DCR are applicable to civilian EMS(TQs, TXA, FDP, CRI/STO2)


• USAISR CPG’s http://usaisr.amedd.army.mil/10_jts.html

• PJ Medcast

• Dirt Medicine

http://usaisr.amedd.army.mil/10_jts.html


We succeed only as we identify in life, or in war, or in anything else, a single overriding objective, and make all other considerations bend to that one objective. -GEN Dwight D. Eisenhower

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cord cunningham, md, mph lieutenant colonel, us army 1st ... · • explore the army implementation...

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