1
|
Joarder M, Noureddine El Moussaoui H, Das A, Williamson F, Wullschleger M. Impact of time and distance on outcomes following tourniquet use in civilian and military settings: A scoping review. Injury 2023; 54:1236-1245. [PMID: 36697284 DOI: 10.1016/j.injury.2023.01.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 12/01/2022] [Accepted: 01/16/2023] [Indexed: 01/19/2023]
Abstract
BACKGROUND The last two decades have seen the reintroduction of tourniquets into guidelines for the management of acute limb trauma requiring hemorrhage control. Evidence supporting tourniquet application has demonstrated low complication rates in modern military settings involving rapid evacuation timeframes. It is unclear how these findings translate to patients who have prolonged transport times from injury in rural settings. This scoping review investigates the relationship between time and distance on metabolic complications, limb salvage and mortality following tourniquet use in civilian and military settings. METHODS A systematic search strategy was conducted using PubMed, Embase, and SafetyLit databases. Study characteristics, setting, mechanism of injury, prehospital time, tourniquet time, distance, limb salvage, metabolic response, mortality, and tourniquet removal details were extracted from eligible studies. Descriptive statistics were recorded, and studies were grouped by ischemia time (< 2 h, 2-4 h, or > 4 h). RESULTS The search identified 3103 studies, from which 86 studies were included in this scoping review. Of the 86 studies, 55 studies were primarily in civilian environments and 32 were based in military settings. One study included both settings. Blast injury was the most common mechanism of injury sustained by patients in military settings (72.8% [5968/8200]) followed by penetrating injury (23.5% [1926/8200]). In contrast, in civilian settings penetrating injury was the most common mechanism (47.7% [1633/3426]) followed by blunt injury (36.4% [1246/3426]). Tourniquet time was reported in 66/86 studies. Tourniquet time over four hours was associated with reduced limb salvage rates (57.1%) and higher mortality rates (7.1%) compared with a tourniquet time of less than two hours. The overall limb salvage and mortality rates were 69.6% and 6.7% respectively. Metabolic outcomes were reported in 28/86 studies with smaller sample sizes and inconsistencies in which parameters were reported. CONCLUSION This scoping review presents literature describing comparatively safe tourniquet application when used for less than two hours duration. However, there is limited research describing prolonged tourniquet application or when used for protracted distances, such that the impact of tourniquet release time on metabolic outcomes and complications remains unclear. Prospective studies utilizing the development of an international database to provide this dataset is required.
Collapse
Affiliation(s)
- Maisah Joarder
- Faculty of Medicine, University of Queensland, Herston, QLD, Australia; Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, QLD, Australia.
| | - Hussein Noureddine El Moussaoui
- Faculty of Medicine, University of Queensland, Herston, QLD, Australia; Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Arpita Das
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Frances Williamson
- Faculty of Medicine, University of Queensland, Herston, QLD, Australia; Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, QLD, Australia; Trauma Service, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Martin Wullschleger
- Faculty of Medicine, University of Queensland, Herston, QLD, Australia; Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, QLD, Australia; Trauma Service, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| |
Collapse
|
2
|
Lee JJ, Hall AB, Carr MJ, MacDonald AG, Edson TD, Tadlock MD. Integrated military and civilian partnerships are necessary for effective trauma-related training and skills sustainment during the inter-war period. J Trauma Acute Care Surg 2022; 92:e57-e76. [PMID: 34797811 DOI: 10.1097/ta.0000000000003477] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Joseph J Lee
- From the Department of Surgery (J.J.L., M.J.C., M.D.T.), Navy Medicine Readiness & Training Command, San Diego, California; 96th Medical Group (A.B.H.), US Air Force Regional Hospital, Eglin AFB, Florida; Uniformed Services University of the Health Sciences (A.G.M.), Bethesda, Maryland; and 1st Medical Battalion (T.D.E.), 1st Marine Logistics Group, Camp Pendleton, California
| | | | | | | | | | | |
Collapse
|
3
|
Gurney JM, Cole WC, Graybill JC, Shackelford SA, Via DK. Maintaining Surgical Readiness While Deployed to Low-Volume Military Treatment Facilities: A Pilot Program for Clinical and Operational Sustainment Training in the Deployed Environment. Mil Med 2020; 185:508-512. [PMID: 32074334 DOI: 10.1093/milmed/usz263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Maintaining readiness among Army surgeons is increasingly challenging because of declining operative experience during certain deployments. Novel solutions should be considered. MATERIALS AND METHODS A pilot program was conducted to rotate surgical teams from a military treatment facility with a low volume of combat casualty care to one with a higher volume. Pre- and postrotation surveys were conducted to measure relative operative experience, trauma experience, and perceived readiness among rotators. RESULTS Operative volumes and trauma volumes were increased and that perceived readiness among rotators, especially those with the fewest previous deployments, was improved. CONCLUSIONS Maintaining readiness among Army surgeons is a difficult task, but a combination of increased trauma care while in garrison, as well as increased humanitarian care during deployments, may be helpful. Additionally, rotating providers from facilities caring for few combat casualties to facilities caring for more combat casualties may also be feasible, safe, and helpful.
Collapse
Affiliation(s)
| | - Will C Cole
- Department of Surgery, Tripler Army Medical Center, 1 Jarrett White Rd, Medical Center, Honolulu, HI 96859
| | - John C Graybill
- Department of Surgery, Brooke Army Medical Center, 3351 Roger Brooke Dr, Fort Sam Houston, TX 78234
| | | | - Darin K Via
- Central Command, 7115 S Boundary Blvd, Tampa, FL 33621
| |
Collapse
|
4
|
Nealeigh MD, Kucera WB, Bradley MJ, Jessie EM, Sweeney WB, Ritter EM, Rodriguez CJ. Surgery at Sea: Exploring the Training Gap for Isolated Military Surgeons. JOURNAL OF SURGICAL EDUCATION 2019; 76:1139-1145. [PMID: 30952458 DOI: 10.1016/j.jsurg.2018.12.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 11/13/2018] [Accepted: 12/10/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Newly-graduated military general surgeons often find themselves isolated at sea, solely responsible for all surgical care of several thousand sailors, regardless of the surgical specialty training required for any individual procedure. This educational need assessment explored trends in afloat surgical care over the last 25 years, and assessed trainees' preparedness for their expected role as an isolated surgeon. DESIGN A sample of deidentified US Navy Ship's Surgeon case logs were reviewed to determine afloat case load trends in 5 common afloat case categories (urologic/gynecologic, anorectal, hernia, appendectomy, and hand/orthopedic/trauma) from 1990s to 2017. Individual procedures were mapped to American College of Surgeons/Military Health System Knowledge, Skills, and Attitudes line items to ensure afloat-relevant skills were identified. Recent military resident case logs were then compared with afloat cases to evaluate relevant trainee experience. SETTING US Navy ships at sea from 1995 to 2017. PARTICIPANTS US Navy afloat-deployed surgeons, totaling 1340 cases within the study period. RESULTS Case log analysis of 1340 surgeries, comprising >200 months at sea, reflected 46 named procedures; 34 of 46 (74%) correlated to an intraoperative knowledge, skills, and attitudes item. The most common surgeries were vasectomy, (304 of 1340, 23%). No difference in case mix was apparent comparing pre- and post-2000 deployments (representing afloat laparoscopic integration) in 4 of 5 categories, while hernias proportionally declined. Case volume per deployment markedly declined overall (p < 0.001) and in each category. Resident case log analysis from 2012 to 2016 showed experience was limited in urologic/gynecologic, orthopedic, and open appendectomy categories. CONCLUSIONS No formal case repository exists for afloat surgery, making detailed analysis problematic. Current training provides excellent surgical education but minimal exposure to rare-but-real cases expected on deployments, which may not translate to competency for the isolated, afloat surgeon. Military surgical leadership should embrace training for these cases and assertively invest in the development of the military's newest surgeons.
Collapse
Affiliation(s)
- Matthew D Nealeigh
- Department of Surgery at the Uniformed Services University, the Walter Reed National Military Medical Center, Bethesda, Maryland.
| | - Walter B Kucera
- Department of Surgery at the Uniformed Services University, the Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Matthew J Bradley
- Department of Surgery at the Uniformed Services University, the Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Elliot M Jessie
- Department of Surgery at the Uniformed Services University, the Walter Reed National Military Medical Center, Bethesda, Maryland
| | - W Brian Sweeney
- Department of Surgery at the Uniformed Services University, the Walter Reed National Military Medical Center, Bethesda, Maryland
| | - E Matthew Ritter
- Department of Surgery at the Uniformed Services University, the Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Carlos J Rodriguez
- Department of Surgery at the Uniformed Services University, the Walter Reed National Military Medical Center, Bethesda, Maryland
| |
Collapse
|
5
|
Anderson KL, Mora AG, Bloom AD, Maddry JK, Bebarta VS. Cardiac massage for trauma patients in the battlefield: An assessment for survivors. Resuscitation 2019; 138:20-27. [PMID: 30825551 DOI: 10.1016/j.resuscitation.2019.02.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 02/14/2019] [Accepted: 02/18/2019] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Survival from traumatic cardiopulmonary arrest (TCA) has been reported at a rate as low as 0-2.6% in the civilian pre-hospital setting, and many consider resuscitation of this group to be futile. The aim of this investigation was to describe patients who received cardiac massage during TCA in a battlefield setting; we also aimed to identify predictors of survival. METHODS We conducted a review of the Department of Defense Trauma Registry to identify patients who received cardiac massage in the battlefield between 2007 and 2014. Patients were also grouped according to location of cardiac arrest: pre-hospital (PH) and in-hospital (IH). The groups were compared and evaluated by injury, transport time, type of resuscitation, and pre-hospital procedures. Outcome variables included survival to discharge and 30-day survival. Categorical variables were analysed using chi-square or Fisher's exact tests. Wilcoxon tests were performed for continuous variables. Regression modelling was used to assess for predictors of survival. RESULTS 75 of all 582 patients (13%, 95% CI 10-16) survived to 30 days, and all survivors were transported out of the battlefield; 23 PH (7.8%, 95% CI 5.2-12) and 52 IH (17%, 95% CI 13-22) patients survived to 30 days (p < 0.001). Closed-chest cardiac massage with the administration of intravenous medications was associated with 30-day survival among IH patients. CONCLUSIONS We report a 13% survival to 30 days among all patients receiving cardiac massage in a battlefield setting. Closed-chest cardiac massage predicted survival among IH TCA victims who also received intravenous medications in this review of combat-related TCA.
Collapse
Affiliation(s)
- Kenton L Anderson
- Stanford University School of Medicine, Department of Emergency Medicine, 900 Welch Road, Suite 350, Palo Alto, CA 94304, United States.
| | - Alejandra G Mora
- United States Air Force 59th MDW/ST, Enroute Care Research Center - United States Army Institute of Surgical Research, 3698 Chambers Pass, Building 3610, Fort Sam Houston, TX 78234, United States
| | - Andrew D Bloom
- San Antonio Military Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston, TX 78234, United States
| | - Joseph K Maddry
- United States Air Force 59th MDW/ST, Enroute Care Research Center - United States Army Institute of Surgical Research, 3698 Chambers Pass, Building 3610, Fort Sam Houston, TX 78234, United States; San Antonio Military Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston, TX 78234, United States
| | - Vikhyat S Bebarta
- University of Colorado School of Medicine, Department of Emergency Medicine, Campus Box B-215, 1240 E. 17th Avenue, Aurora, CO 80045, United States
| |
Collapse
|
6
|
Military Weapon Injury Among Illegal Immigrants at the Southern Border of Israel: A Single Level I Trauma Center Series. J Immigr Minor Health 2016; 19:1420-1426. [PMID: 27318937 DOI: 10.1007/s10903-016-0447-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
This article describes the characteristics of injuries of illegal immigrants admitted to a Level I trauma center after being shot at the southern border of Israel. This is a retrospective descriptive study. Some of the variables were compared to a group of soldiers who sustained penetrating injury at the same region where the illegal migrant were injured. The study includes 162 patients. The lower body absorbed a higher percentage of the injuries (61 %). The hospitalization time is longer for the migrant patients compared to the soldiers (13 ± 2 vs. 3 ± 0.3 days p = 0.0001). This study on wounded immigrants shows that a conjoint military and civilian system can result in favourable outcomes. The manuscript is an attempt to bring this unique situation, its type of injuries, and the difficulties of the health system in coping with it, to the notice of all authorities that may address a similar challenge.
Collapse
|
7
|
Murphy LS, Zangaro GA, Gadsden E. Students’ Experiences With Military Nurses as Faculty. J Nurs Educ 2012; 51:204-11. [DOI: 10.3928/01484834-20120224-02] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2011] [Accepted: 01/25/2012] [Indexed: 11/20/2022]
|
8
|
Borzotta A. Civilian and Military Trauma: Does Civilian Training Prepare Surgeons for the Battlefield?. Am Surg 2011. [DOI: 10.1177/000313481107700115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|