Combat casualty care research at the U.S. Army Institute of Surgical Research

Association between traumatic brain injuries and ketamine infusion side effects following combat injury

INTRODUCTION

Ketamine is a vital component for acute pain management in emergency trauma care for both civilian and military hospitals. This preliminary analysis examined whether combat-injured US service members sustaining traumatic brain injuries (TBI) experienced increased odds of ketamine side effects compared with those without TBI.

METHODS

This preliminary analysis included combat-injured service members, ages ≥18 years with documented pain scores during the 24 hours before and 48 hours after receiving an intravenous ketamine infusion at Walter Reed National Military Medical Center (WRNMMC) between 2007 and 2014. Logistic regression modeling examined the association between TBI and ketamine side effects (eg, hallucinations, nightmares, dysphoria, nausea, decreased oxygen saturation) during hospitalisation.

RESULTS

Of the 77 patients, 62% presented with a documented TBI. Side effects were documented for 18.8% of those without TBI and 24.4% of those with TBI. Analyses were unable to find evidence against the null hypothesis with the current sample size, even when adjusting for injury characteristics and preinfusion opioid doses (adjusted OR=0.90 (95% CI 0.26 to 3.34), p=0.87).

CONCLUSION

In this small sample of combat-injured service members, we were unable to detect a difference in ketamine-related side effects by documented TBI status. These hypothesis-generating findings support the need for future studies to examine the use of intravenous ketamine infusions for pain management, and subsequent care outcomes in patients who experience polytraumatic trauma inclusive of TBI.

Infusion Pump in UH60L/M Flight in Afghanistan: Why Failures Occur

The ALARIS MSIII Infusion Pump (CareFusion, San Diego, CA) uses 3 separate alarms designed to prevent air emboli: "check air sensor," "air in lower tubing," and "air in line." It is assumed that ambient pressure changes cause air emboli that lead to pump failure although evidence to support this is limited. In this small study, the MSIII proved to be highly resilient and able to maintain function even after large repetitive emboli. Although unproven, it is more likely that these alarms are usually caused by loosening of the intravenous tubing within the pump's collar. This disjointing of the tubing and the ultrasonic sensor can be perceived as an air embolus leading to severe consequences. If the user attempts the clear air function, the pump will not resume function. Problems such as this may have been related to at least 1 reported patient death. More research is needed to determine the cause of these alarms and determine the exact cause. Patient safety can potentially be improved at all levels including manufacturer modifications and operator training. It seems reasonable that the manufacturer should design a mode ("transport mode") that allows the pump to function even with air emboli.

Advancing the Pain Agenda in the Veteran Population

The Veterans Health Administration (VHA) provides medical care for Veterans after leaving the military. The combination of multiple deployments and battlefield exposures to physical and psychological trauma results in a higher prevalence and complexity of chronic pain in Veterans than in the general public. The VHA and the Department of Defense work together to develop a single standard of stepped pain management appropriate for all settings from moment of injury or disease onset. This article describes the education, academic detailing, and clinical programs and policies that are transforming pain care in the VHA.

Medical rescue of naval combat: challenges and future

There has been no large-scale naval combat in the last 30 years. With the rapid development of battleships, weapons manufacturing and electronic technology, naval combat will present some new characteristics. Additionally, naval combat is facing unprecedented challenges. In this paper, we discuss the topic of medical rescue at sea: what challenges we face and what we could do. The contents discussed in this paper contain battlefield self-aid buddy care, clinical skills, organized health services, medical training and future medical research programs. We also discuss the characteristics of modern naval combat, medical rescue challenges, medical treatment highlights and future developments of medical rescue at sea.

A totally recombinant human fibrin sealant

BACKGROUND

Applications of plasma-derived human fibrin sealants (pdhFS) have been limited because of cost, limited supply of pathogen-screened plasma, the need for bioengineering improvements, and regulatory issues associated with federal approval. We describe a totally recombinant human fibrin sealant (rhFS), which may engender an abundant, safe, and cost-effective supply of efficacious fibrin sealant.

MATERIALS AND METHODS

A first-generation rhFS made from recombinant human fibrinogen (rhFI; produced in the milk of transgenic cows), activated recombinant human factor XIII (rhFXIIIa; produced in yeast), and recombinant human thrombin (rhFIIa; purchased, made in animal cell culture) was formulated using thromboelastography (TEG). The hemostatic efficacy of rhFS versus commercial pdhFS was compared in a nonlethal porcine hepatic wedge excision model.

RESULTS

The maximal clot strength of rhFS measured in vitro by TEG was not statistically different than that of pdhFS. TEG analysis also showed that the rhFS gained strength more quickly as reflected by a steeper α angle; however, the rhFS achieved this clot strength with a 5-fold lower factor I content than the pdhFS. When these fibrin sealants were studied in a porcine hepatic wedge excision model, the hemostatic scores of the rhFS were equivalent or better than that of the pdhFS.

CONCLUSIONS

The bioengineered rhFS had equivalent or better hemostatic efficacy than the pdhFS in a nonlethal hemorrhage model, despite the factor I concentration in the rhFS being about one-fifth that in the pdhFS. Because the rhFS is amenable to large-scale production, the rhFS has the potential to be more economical and abundant than the pdhFS, while having a decreased risk of blood-borne pathogen transmission.

[Vacuum-assisted closure of head and neck wounds]

OBJECTIVE

Since the early 1990s, vacuum-assisted closure (VAC) therapy has been used to treat acute and chronic wounds in almost all disciplines of surgery in Germany. Taking this into consideration, the use of vacuum therapy in the area of head and neck surgery was examined.

METHODS

A literature review using MEDLINE (with PubMed) and EMBASE as well as a Cochrane search was performed on 15 December 2010. Search terms included "vacuum therapy", "vacuum-assisted closure", "V.A.C.", "VAC", "(topical) negative pressure (wound therapy)".

RESULTS

There were 1,502 peer-reviewed articles about "vacuum therapy" concerning all medical fields in literature. There were a total of 37 publications from the discipline of head and neck surgery (538 patients). Although benefits for the patients are consistently reported, these results are usually presented only in case reports or case series (evidence level IV and V). Positive results are mainly observed for the treatment of lifting defects in reconstructive surgery and for the treatment of acute and chronic soft tissue defects of the neck. Only little experience exists in the vacuum therapy of war wounds in the head and neck region.

CONCLUSION

Due to its advantages (i.e., hygienic temporary wound care with support of the continuous decontamination, wound drainage, promotion of granulation tissue formation, and effective wound conditioning), VAC is an integral and indispensable part of modern wound treatment. Analogous to this general experience, a benefit must also be assumed for head and neck wounds. High-quality and reliable studies on the use of VAC must be performed to verify this observation and the future reimbursement of in- and outpatient wound VAC treatment.

Fluid Therapy in Trauma

Advances in shock resuscitation have occurred as a result of various military conflicts. Primary objective of trauma care is to minimize or reverse shock, avoiding the lethal triad of hypothermia, acidosis, and coagulopathy. The concept of Damage Control Resuscitation has evolved along with "damage control surgery" which includes hypotensive and haemostatic resuscitation, where small aliquots of fluid are infused, with hypovolaemia and hypotension tolerated as a necessary evil until definitive haemorrhage control can be achieved. In the initial stages of trauma resuscitation the precise fluid, crystalloid or colloid, used is probably not important as long as an appropriate volume is given. Haemostatic resuscitation includes early use of fresh frozen plasma in a 1:1 ratio with packed red cells with emphasis on whole blood, frequent cryo precipitates and platelets and the use of recombinant Factor VII for control of bleeding.