Avi Benov

Tranexamic acid at the point of injury: the Israeli combined civilian and military experience.

BACKGROUND Accumulating evidence established the benefit of tranexamic acid (TXA) for traumatic bleeding in the hospital setting. TXA use in the field (at or near the point of injury [POI]) was described in the military setting but not in the civilian one. The current study describes the Israeli combined experience (civilian and military) of administering TXA in the field. METHODS The Israel Defense Forces (IDF) and Magen David Adom (MDA) (the national Israeli civilian emergency medical service) protocols for giving TXA at the POI are presented. We then review all trauma patients who received TXA in the field in accord with either protocol. Data were abstracted from the IDF Trauma Registry and from the MDA database. RESULTS Data regarding casualties treated with TXA by the IDF Medical Corps and MDA between December 2011 and August 2013 are presented. One hundred three casualties who received TXA in the field were identified. The median age was 26.5 years, and 83 (88%) were male. The mechanism of injury was penetrating in 48 cases (51%). POI data indicate slightly higher injury severity for the group of patients treated by MDA compared with patients treated by the IDF (systolic blood pressure, 90 mm Hg vs. 110 mm Hg; Glasgow Coma Scale [GCS] score, 11 vs. 15; hemoglobin, 11.9 vs. 13.3; p < 0.05). CONCLUSION On the basis of our combined data, it appears that administering TXA in the field is feasible in the civilian and the military setting. Lessons learned in military settings are applicable to civilian medical systems. Action investigations and comparison of the different protocols may further improve treatment at or near the POI. LEVEL OF EVIDENCE Therapeutic study, level V.

Prehospital use of hemostatic dressings by the Israel Defense Forces Medical Corps: A case series of 122 patients.

BACKGROUND Hemostatic dressings are advanced topical dressings designed to control hemorrhage by enhancing clot formation. These dressings may be effective when used on injuries sustained in junctional zones. The Israeli Defense Forces Medical Corps (IDF-MC) chose to equip its medical personnel with the QuikClot Combat Gauze. There is a paucity of data describing clinical use and results of hemostatic dressing especially at the point of injury. The purpose of this article was to report the IDF-MC experience with prehospital use of the QuikClot Combat Gauze in junctional zones in a case series retrieved from the IDF Trauma Registry. METHODS All IDF Trauma Registry documented cases of prehospital use of hemostatic dressings in the IDF-MC between January 2009 and September 2014 were retrieved. Data collection included injury mechanism, wound location, reported success of hemostatic dressing, tourniquet use, lifesaving interventions, mortality, and caregiver identity. RESULTS A total of 122 patients on whom 133 hemostatic dressings were applied were identified. Median age was 22 years. Of the patients, 118 (96.7%) were male and 2 (1.6%) were female (missing, n = 2). Injury mechanism was penetrating in 104 (85.2%), blunt in 4 (3.3%), and combined in 14 (11.5%) patients. Seven patients (5.9%) died. Thirty-seven dressings (27.8%) were used for junctional hemorrhage control (pelvis, shoulder, axilla, buttocks, groin, neck), and 92 dressings (72.1%) were placed in nonjunctional areas (missing, n = 4). Nonjunctional dressings included 63 (47.4%) applied to the extremities, 14 (10.5%) to the back, and 4 (3%) to the head. Hemostatic dressing application was reported as successful in 88.6% (31 of 35 available; missing, n = 2) of junctional hemorrhage applications and in 91.9% (57 of 62 available; missing, n = 1) of extremity hemorrhage applications. CONCLUSION Hemostatic dressings seem to be an effective tool for junctional hemorrhage control and should be considered as a second-line treatment for extremity hemorrhage control at the point of injury. LEVEL OF EVIDENCE Therapeutic study, level V.

Role I trauma experience of the Israeli Defense Forces on the Syrian border.

I has been in a state of conflict with the bordering country of Syria since 1948. Beginning in February 2011, Syria has been in a state of civil war that has taken the lives of civilians and resulted in more than a million refugees. In February 2013, casualties from the fighting in Syria arrived at the Israeli border seeking medical assistance. Despite the challenging scenario, members of the Israeli Defense Forces (IDF) provided care to this group of injured civilians. Since that time, such medical care was available to men, women, and children who arrive at the Syrian border. In contrast to endeavors in which the IDF-Medical Corps (MC) has deployed to sites of calamities around the globe, this operation began as one of expediency to provide humanitarian care on its own domestic border. As in other locations throughout the country, the IDF-MC has structured units at the Syrian border in echelons beginning with the Role I Battalion Aid Station. The Battalion Aid Station is composed of two medical teams, each consisting of an advanced life support (ALS) provider (physician or a paramedic, EMT-P) and three combat medics. These teams are mobilized by armored ambulances and provide care to anyone in need including measures of combat casualty care and a select number of advanced techniques such as the administration of reconstituted dried plasma as a resuscitative fluid. In the past months, with higher numbers of casualties at the border, additional Role 1 teams have been deployed in this region. Casualties arriving at the Role I team location are treated according to Israeli standards, adhering to clinical practice guidelines (CPGs) of the IDF-MC. Treating these casualties without knowledge of the happenings within Syria and without control of their time of presentation is especially challenging. After triage and stabilization, casualties requiring greater levels of care are evacuated to higher echelons in the form of a dedicated Role 2+ facility to provide lifesaving interventions (LSIs) and mid-sized Israeli tertiary civilian medical centers, which serve as the Role III echelons, providing advanced care. Demographic, injury, and treatment information on casualties is captured within these levels of care, and analysis of these data provides process improvement and maintenance of practice standards (i.e., CPGs). As part of the IDF-MC ongoing process of data collection, analysis, and learning, the objective of this report was to describe the unique Role 1 IDF experience including the types of patients, patterns of injury, and management strategies. Additional objectives were to characterize lessons learned and to identify strategies that may be useful in supporting combat casualty care around the world.

Intravenous access in the prehospital settings: What can be learned from point-of-injury experience.

BACKGROUND Intravenous (IV) access has an essential role in the care provided for trauma patients, allowing for transfusion of blood products, fluids, and drugs. Decisions should be made regarding the necessity of IV access while considering cost-benefit of the procedure in terms of delayed evacuation times. METHODS A retrospective review of all trauma patients in whom at least one attempt at IV access was performed were reviewed. Data were abstracted from the Israeli Defense Force Trauma Registry. RESULTS Of 7,476 patients, 1,082 patients who had at least one documented attempt at IV access between January 1997 and April 2013 were included in this study. Overall cumulative success rate at IV access was 82%. Success rates for IV access were 86%, 68%, 63%, 50%, 20% for the first, second, third, fourth, and fifth attempts, respectively. The first and second attempts accounted for 96% of the successful procedures. Mortality in patients for whom IV access was successful was 13%; mortality in patients for whom IV access was not successful was 35%. CONCLUSION The success rate of IV access declined with each subsequent attempt. There was minimal improvement of overall success rate seen after the second attempt. Our findings suggest that the inability to obtain peripheral venous access is associated with severe injuries. These finding support a policy of limiting the number of venous access attempts to two attempts, followed by a reevaluation of need for parenteral access. Improved training of combat medics and paramedics might marginally increase the success rates of IV access. Point-of-injury data, used for ongoing learning and research, form the ground for improving combat casualty care and thus help saving lives. LEVEL OF EVIDENCE Therapeutic study, level IV.

Confidence–Competence Mismatch and Reasons for Failure of Non-Medical Tourniquet Users

Abstract Objective: Tourniquet application is a lifesaving skill taught worldwide in first aid bleeding control courses. We observed performance among non-medical users of tourniquets in their confidence, competence, and reasons for failure. Methods: 179 Israeli military recruits without prior medical training underwent their standard first aid course where they learned Combat Application Tourniquet (CAT; Composite Resources, Rock Hill, SC, USA) use. After course completion, they self-reported confidence in tourniquet use. User performance was assessed 7–14 days later using a HapMed™ mannequin that assessed time, pressure, and blood loss. Competent performance required in aggregate: 1) use with pressure of 200 mmHg or more, 2) hemorrhage volume of less than 638 mL, and 3) correct placement of the tourniquet. For failed performance, a reason for failure was reported independently by both the user and an expert observer. Results: 45 of 179 user performances (25%) were competent. Users who reported high confidence had only a slightly higher chance of achieving competence in tourniquet application (r = 0.17, p = 0.022). The most common reason for failure was excess slack in the CATs strap (experts 55%, users 39%), and too few turns of the windlass (23% and 31%, respectively) was the second most common reason. Expert and user evaluations had poor agreement (κ = 0.44, 95% CI 0.32–0.56). Conclusion: The most common reason for failed use of tourniquets among non-medical users was excess slack in the tourniquet strap. Users self-evaluated their performance inaccurately and demonstrated a confidence-competence mismatch. These pitfalls in performance may help tourniquet instructors improve training of caregivers.

Analysis of injury patterns and roles of care in US and Israel militaries during recent conflicts: Two are better than one.

BACKGROUND As new conflicts emerge and enemies evolve, military medical organizations worldwide must adopt the “lessons learned.” In this study, we describe roles of care (ROCs) deployed and injuries sustained by both US and Israeli militaries during recent conflicts. The purpose of this collaborative work is facilitate exchange of medical data among allied forces in order to advance military medicine and facilitate strategic readiness for future military engagements that may involve less predictable situations of evacuation and care, such as prolonged field care. METHODS This retrospective study was conducted for the periods of 2003 to 2014 from data retrieved from the Department of Defense Trauma Registry and the Israel Defense Force (IDF) Trauma Registry. Comparative analyses included ROC capabilities, casualties who died of wounds, as well as mechanism of injury, anatomical wound distribution, and Injury Severity Score of US and IDF casualties during recent conflicts. RESULTS Although concept of ROCs was similar among militaries, the IDF supports increased capabilities at point of injury and Role 1 including the presence of physicians, but with limited deployment of other ROCs; conversely, the US maintains fewer capabilities at Role 1 but utilized the entire spectrum of care, including extensive deployment of Roles 2/2+, during recent conflicts. Casualties from US forces (n = 19,005) and IDF (n = 2,637) exhibited significant differences in patterns of injury with higher proportions of casualties who died of wounds in the US forces (4%) compared with the IDF (0.6%). CONCLUSIONS As these data suggest deployed ROCs and injury patterns of US and Israeli militaries were both conflict and system specific. We envision that identification of discordant factors and common medical strategies of the two militaries will enable strategic readiness for future conflicts as well as foster further collaboration among allied forces with the overarching universal goal of eliminating preventable death on the battlefield.

Battlefield pain management: A view of 17 years in Israel Defense Forces

BACKGROUND Pain control in trauma is an integral part of treatment in combat casualty care (CCC). More soldiers injured on the battlefield will need analgesics for pain than those who will need lifesaving interventions (LSI). It has been shown that early treatment of pain improves outcomes after traumatic injury, whereas inadequate treatment leads to higher rates of PTSD. The purpose of this article is to report the Israel Defense Forces Medical Corps (IDF-MC) experience with point of injury (POI) use of analgesia. METHODS All cases documented in the IDF Trauma Registry (ITR) between January 1997 and December 2014 were examined. All cases of POI pain medications were extracted. Data collection included mechanism of injury, wound distribution, pain medication administered, mortality, and provider type. RESULTS Of 8,576 patients, 1,056 (12.3%) patients who had at least one documented pain management treatment were included in this study. Demographics of the study population included 94.2% men and 5.8% women with a median age of 21 years. Injury mechanisms included 40.3% blast injuries (n = 426) and 29% gunshot injuries (306). Of 1,513 injured body regions reported, 52% (787) were extremity wounds (upper and lower), 23% (353) were truncal wounds, and 17.7% (268) were head and neck injuries. A total of 1,469 episodes of analgesic treatment were reported. The most common types of analgesics were morphine (74.7%, 1,097 episodes), ketamine (9.6%, 141 episodes), and fentanyl (13.6%, 200 episodes). Of the patients, 39% (413) received more than one type of analgesic. In 90.5% of cases, analgesia was administered by a physician or a paramedic. Over the span of the study period (1997–2014), types of analgesics given by providers at POI had changed, as fentanyl was introduced to providers. A total of 801 LSIs were performed on 379 (35.9%) patients receiving analgesia, and no adverse events were found in any of the casualties. CONCLUSION Most casualties at POI did not receive any analgesics while on the battlefield. The most common analgesics administered at POI were opioids and the most common route of administration was intravenously. This study provides evidence that over time analgesic administration has gained acceptance and has been more common place on the battlefield. Increasingly, more casualties are receiving pain management treatment early in CCC along with LSIs. We hope that this shift will impact CCC by reducing PTSD and overall morbidity resulting from inadequate management of acute pain.

The effect of blood transfusion on compensatory reserve: A prospective clinical trial

BACKGROUND Bleeding activates the body’s compensatory mechanisms, causing changes in vital signs to appear late in the course of progressive blood loss. These vital signs are maintained even when up to 30% to 40% of blood volume is lost. Laboratory tests such as hemoglobin, hematocrit, lactate, and base deficit levels do not change during acute phase of bleeding. The compensatory reserve measurement (CRM) represents a new paradigm that measures the total of all physiological compensatory mechanisms, using noninvasive photoplethysmography to read changes in arterial waveforms. This study compared CRM to traditional vital signs and laboratory tests in actively bleeding patients. METHODS Study patients had gastrointestinal bleeding and required red blood cell (RBC) transfusion (n = 31). Control group patients had similar demographic and medical backgrounds. They were undergoing minor surgical procedures and not expected to receive RBC transfusion. Vital signs, mean arterial pressure, pulse pressure, hemoglobin and hematocrit levels, and CRM were recorded before and after RBC transfusion or the appropriate time interval for the control group. Receiver operator characteristic curves were plotted and areas under the curves (AUCs) were compared. RESULTS CRM increased 10.5% after RBC transfusion, from 0.77 to 0.85 (p < 0.005). Hemoglobin level increased 22.4% after RBC transfusion from 7.3 to 8.7 (p < 0.005). Systolic and diastolic blood pressure, mean arterial pressure, pulse pressure, and heart rate did change significantly. The AUC for CRM as a single measurement for predicting hemorrhage at admission was 0.79, systolic blood pressure was 0.62, for heart rate was 0.60, and pulse pressure was 0.36. CONCLUSIONS This study demonstrated that CRM is more sensitive to changes in blood volume than traditional vital signs are and could be used to monitor and assess resuscitation of actively bleeding patients. LEVEL OF EVIDENCE Care management, level II.

Platelets derived from fresh and cold-stored whole blood participate in clot formation in rats with acute traumatic coagulopathy

The in vitro haemostatic functions of fresh whole blood (FWB) are well preserved after cold storage. This study aimed to determine whether platelets derived from FWB and stored whole blood (SWB) contribute to clot formation in tissue injury after transfusion into coagulopathic rats with polytrauma/haemorrhage (T/H). The rats were resuscitated 1 h after trauma with FWB or SWB collected from green fluorescence protein (GFP) transgenic rats. After transfusion, a liver incision was made and the tissue was collected 10 min after injury to identify GFP+ platelets by immunohistochemistry. In comparison to FWB, platelet aggregation to adenosine diphosphate and protease‐activated receptor‐4 was reduced by 35% and 20%, and clotting time was shortened by 25% in SWB. After transfusion, SWB led to a significant increase in platelet activation as measured by an elevation of CD62P and phosphatidylserine expression. The platelets from SWB were in a higher activation state, and showed higher clearance rate and formation of platelet‐leucocyte aggregates than those from FWB after transfusion. Platelets from both FWB and SWB were equivalently incorporated into the clot at the incisional site, as determined by co‐localization of CD61 and GFP. This study suggests that SWB contributes to haemostatic function and is an effective alternative resource to treat trauma patients.

Whole Blood Transfusion

Whole blood is the preferred product for resuscitation of severe traumatic hemorrhage. It contains all the elements of blood that are necessary for oxygen delivery and hemostasis, in nearly physiologic ratios and concentrations. Group O whole blood that contains low titers of anti-A and anti-B antibodies (low titer group O whole blood) can be safely transfused as a universal blood product to patients of unknown blood group, facilitating rapid treatment of exsanguinating patients. Whole blood can be stored under refrigeration for up to 35 days, during which it retains acceptable hemostatic function, though supplementation with specific blood components, coagulation factors or other adjuncts may be necessary in some patients. Fresh whole blood can be collected from pre-screened donors in a walking blood bank to provide effective resuscitation when fully tested stored whole blood or blood components are unavailable and the need for transfusion is urgent. Available clinical data suggest that whole blood is at least equivalent if not superior to component therapy in the resuscitation of life-threatening hemorrhage. Low titer group O whole blood can be considered the standard of care in resuscitation of major hemorrhage.