Avraham Yitzhak

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.

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.

Prehospital administration of freeze-dried plasma, is it the solution for trauma casualties?

BACKGROUND Hemorrhage is the leading cause of possible preventable death in the battlefield. There is an increasing evidence for the effectiveness of blood component therapy in general, and plasma infusion in particular but their use is less applicable in the prehospital setting due to logistic difficulties. Israeli Defense Force has implemented the use of freeze-dried plasma (FDP) at the point of injury (POI), this adoption of FDP use entailed doubts regarding the feasibility and effectiveness of this practice. In this article, we present our experience with the use of FDP at the POI and prehospital setting regarding the feasibility, safety, adverse reactions, and adherence to clinical practice guidelines. METHODS This is a descriptive retrospective cohort study based on all casualties receiving FDP during January 2013 to June 2016. The study describes the injury, treatment, and outcome characteristics from POI until hospital discharge. RESULTS During the study period, 109 casualties received FDP. The majority were men, aged 18 years to 35 years. Multiple severe injuries were found in almost half of the casualties, 78% had penetrating injury, and more than half were involved in a multicasualty event. Eighty-three percent were treated with one unit of FDP, 13% with two units, and 4% casualties with three units, nine patients (8.2%) were also treated in the prehospital setting with packed red blood cells. Fifty-seven percent fulfilled at least one criterion for the administration of FDP. Lifesaving interventions were required in 64%. In five (4.6%) cases, there were difficulties with FDP administration. Side effects were reported in one female patient. CONCLUSION This study supports the usage feasibility of FDP at the POI and in the prehospital setting. Further adjustment of the clinical practice guidelines is required basing it not only on pathophysiologic parameters but also on clinical judgment. Further investigation of the available data is required to learn about the effectiveness of FDP at POI. Level of Evidence Retrospective case series study, level IV.BACKGROUND Hemorrhage, is the leading cause of possible preventable death in the battlefield. There is an increasing evidence for the effectiveness of blood component therapy in general, and plasma infusion in particular but their use is less applicable in the pre-hospital setting due to logistic difficulties. Israeli Defense Force has implemented the use of freeze dried plasma (FDP) at the point of injury (POI), this adoption of FDP use entailed doubts regarding the feasibility and effectiveness of this practice. In this manuscript we present our experience with the use of FDP at the POI and pre-hospital setting regarding the feasibility, safety, adverse reactions and adherence to clinical practice guidelines (CPG). METHODS This is a descriptive retrospective cohort study based on all casualties receiving FDP during January 2013 to June 2016. The study describes the injury, treatment and outcome characteristics from POI until hospital discharge. RESULTS During the study period 109 casualties received FDP. The majority were male, aged 18-35 years old. Multiple severe injuries, were found in almost half of the casualties, 78% had penetrating injury and more than half were involved in a multi casualty event. 83% were treated with one unit of FDP, 13% with two units and 4% casualties with three units, nine patients (8.2%) were also treated in the prehospital setting with PRBC. 57% fulfilled at least one criteria for the administration of FDP. Lifesaving interventions were required in 64%. In five cases (4.6%) there were difficulties with FDP administration, Side effects were reported in one female patient. CONCLUSION This study supports the usage feasibility of FDP at the POI and in the pre-hospital setting. Further adjustment of the CPG is required basing it not only on patho-physiological parameters but also on clinical judgment. Further investigation of the available data is required in order to learn about the effectiveness of FDP at POI. LEVEL OF EVIDENCE Level IV retrospective case series study.

Point of injury tourniquet application during Operation Protective Edge - what de we learn?

BACKGROUND Hemorrhage is a leading cause of preventable death on the battlefield. Timely tourniquet application to massively bleeding extremity wounds is critical for casualty survival albeit with reported adverse effects to extremity integrity. The aim of this study was to describe the immediate- and short-term outcomes of point of injury (POI) tourniquet applications during “Operation Protective Edge” (OPE). METHODS A case series study regarding tourniquet application at the POI during OPE was collected. The data gathered included reports by medical providers at the POI, aerial and land evacuation vehicles, and receiving hospitals. Variables collected included, the number of tourniquet applications, caregiver level, tourniquet type, limb characters, tourniquet effectiveness, in-hospital procedures, complications, and short-term limb outcome. RESULTS During OPE, the Israeli Defense Forces Medical Corps treated 704 casualties. Of these, 90 casualties were treated with 119 tourniquets of which 79 survived. Penetrating trauma was the mechanism of injury in 97.8% (88 of 90) of the casualties. Injuries sustained from improvised explosive devices and shrapnel were related to the use of more than one tourniquet per casualty and per limb (p = 0.034). The success rate of the first tourniquet was reported to be 70% (84 of 119), regardless of caregiver level (p = 0.56), tourniquet type (p = 0.16), or limb characters (p = 0.48). Twenty-seven (25.7%) of 105 of the tourniquets were converted to direct pressure dressings enroute to receiving hospitals two of the conversions failed and thus a new tourniquet was applied. Fasciotomy was performed on eight casualties (a single limb in each). Vascular injury was presumed to be the indication for fasciotomy in three of these cases, in the other five limbs (6%, 5 of 85), no vascular involvement was discovered during surgery, and the fasciotomy is suspected as tourniquet related. 7%) 6 of 85) suffered from neurological sequela that could not be explained by their primary injury. Total complication rate was 11.7% (10 of 85) (one patient had both fasciotomy and neural complication without vascular injury). CONCLUSION Tourniquet use on the battlefield is a simple method of eliminating preventable death, we believe that clinical practice guidelines should promote liberal use of tourniquets by trained combatants and medical personnel with abilities to convert to direct pressure hemorrhage control when possible since an unjustified tourniquet application risks low rates minor morbidity, whereas a justifiable tourniquet not applied may be lethal. LEVEL OF EVIDENCE Epidemiologic study, level III; Therapeutic study, level IV.

Comparison of the performance of battery-operated fluid warmers

Objectives Warming intravenous fluids is essential to prevent hypothermia in patients with trauma, especially when large volumes are administered. Prehospital and transport settings require fluid warmers to be small, energy efficient and independent of external power supply. We compared the warming properties and resistance to flow of currently available battery-operated fluid warmers. Methods Fluid warming was evaluated at 50, 100 and 200 mL/min at a constant input temperature of 20°C and 10°C using a cardiopulmonary bypass roller pump and cooler. Output temperature was continuously recorded. Results Performance of fluid warmers varied with flows and input temperatures. At an input temperature of 20°C and flow of 50 mL/min, the Buddy Lite, enFlow, Thermal Angel and Warrior warmed 3.4, 2.4, 1 and 3.6 L to over 35°C, respectively. However, at an input temperature of 10°C and flow of 200 mL/min, the Buddy Lite failed to warm, the enFlow warmed 3.3 L to 25.7°C, the Thermal Angel warmed 1.5 L to 20.9°C and the Warrior warmed 3.4 L to 34.4°C (p<0.0001). Conclusion We found significant differences between the fluid warmers: the use of the Buddy Lite should be limited to moderate input temperature and low flow rates. The use of the Thermal Angel is limited to low volumes due to battery capacity and low output temperature at extreme conditions. The Warrior provides the best warming performance at high infusion rates, as well as low input temperatures, and was able to warm the largest volumes in these conditions.

Comparison of Two Intraosseous Devices: The NIO Versus the EZ-IO by Novice Users-A Randomized Cross Over Trial

Abstract Background: During resuscitation in the field, intraosseous (IO) access may be achieved using a variety of available devices, often attempted by inexperienced users. Aim: We sought to examine the success rate and ease-of-use ratings of an IO device, the NIO® (New Intraosseous Persys Medical, Houston, TX, USA) in comparison to the Arrow® EZ-IO® (Teleflex Medical Research Triangle Park, NC, USA) by novice users. Methods: We performed a randomized crossover trial. The study model was a porcine hind leg which was cut distally in order to expose the marrow. The Study population was composed of pre-graduate medical students without prior experience in IO use, all designated future field physicians. The students underwent instruction and practiced the use of both devices. After practice completion, each student attempted a single IO insertion with both devices sequentially in randomized fashion. Success was defined as a flow of fluid through the bone marrow after a single IO attempt. Investigators which determined the success rate were blinded to the used device. Results: 50 users (33 males, 17 females) participated in the trial, mean age of 21.7 years (±1). NIO users were successful in 92% (46/50) attempts while EZ-IO user success rate was 88% (44/50). NIO success rates were comparable to those of EZ-IO (p = NS). Results were similar when examining only the initial device used. Median score of ease of use was 4 (5 point Likert scale) in both devices (p = NS). 54% (27/50) of the participants preferred using the EZ-IO over the NIO (p = NS). Conclusion: Novice users were equally successful in establishing IO access with the NIO® in comparison to the EZ-IO® in a porcine model.

Terrorist Stabbings—Distinctive Characteristics and How to Prepare for Them

BACKGROUND The number of terror attack incidents is on the increase worldwide. The knife is one of the weapons most commonly used among terrorists. Appropriate preparation in trauma units for coping with the increasing numbers of terrorist-inflicted stabbings is different from the preparation suitable for civilian stabbings. Therapeutic and logistic guidelines need to be adjusted to accommodate those differences. OBJECTIVES Characterize the unique injuries related to terrorist stabbing, and suggest preparedness actions. METHODS Retrospective data on all terrorist-inflicted stabbing incidents between September 2015 and May 2016 were retrieved from the database of the national Israeli emergency medical services and from the Israeli Defense Forces Medical Corps records. RESULTS There were a total of 414 civilian victims (34 fatalities) of terror incidents. Of these, 161 involved stabbings during 106 separate incidents. There was more than 1 stab wound per patient in approximately 60% of cases, and more than 1 victim in approximately 40% of cases. Unlike civilian stabbings, terrorist stabbings were characterized by more commonly occurring to the upper part of the body, being executed by large knives with high force, and involving multiple and more severe injuries. CONCLUSION There is a clear distinction between the characteristics of wounds resulting from civilian stabbings and those incurred by acts of terror. Terrorists intend to injure as many random victims as possible, and trauma units need to be prepared to cope with the simultaneous admission of multiple patients with penetrating and often life-threatening knife wounds.