Elon Glassberg

Freeze-dried plasma at the point of injury: from concept to doctrine.

ABSTRACT While early plasma transfusion for the treatment of patients with ongoing major hemorrhage is widely accepted as part of the standard of care in the hospital setting, logistic constraints have limited its use in the out-of-hospital setting. Freeze-dried plasma (FDP), which can be stored at ambient temperatures, enables early treatment in the out-of-hospital setting. Point-of-injury plasma transfusion entails several significant advantages over currently used resuscitation fluids, including the avoidance of dilutional coagulopathy, by minimizing the need for crystalloid infusion, beneficial effects on endothelial function, physiological pH level, and better maintenance of intravascular volume compared with crystalloid-based solutions. The Israel Defense Forces Medical Corps policy is that plasma is the resuscitation fluid of choice for selected, severely wounded patients and has thus included FDP as part of its armamentarium for use at the point of injury by advanced life savers, across the entire military. We describe the clinical rationale behind the use of FDP at the point-of-injury, the drafting of the administration protocol now being used by Israel Defense Forces advanced life support providers, the process of procurement and distribution, and preliminary data describing the first casualties treated with FDP at the point of injury. It is our hope that others will be able to learn from our experience, thus improving trauma casualty care around the world.

Trauma hemostasis and oxygenation research position paper on remote damage control resuscitation: definitions, current practice, and knowledge gaps.

ABSTRACT The Trauma Hemostasis and Oxygenation Research Network held its third annual Remote Damage Control Resuscitation Symposium in June 2013 in Bergen, Norway. The Trauma Hemostasis and Oxygenation Research Network is a multidisciplinary group of investigators with a common interest in improving outcomes and safety in patients with severe traumatic injury. The network’s mission is to reduce the risk of morbidity and mortality from traumatic hemorrhagic shock, in the prehospital phase of resuscitation through research, education, and training. The concept of remote damage control resuscitation is in its infancy, and there is a significant amount of work that needs to be done to improve outcomes for patients with life-threatening bleeding secondary to injury. The prehospital phase of resuscitation is critical in these patients. If shock and coagulopathy can be rapidly identified and minimized before hospital admission, this will very likely reduce morbidity and mortality. This position statement begins to standardize the terms used, provides an acceptable range of therapeutic options, and identifies the major knowledge gaps in the field.

Remote damage control resuscitation and the Solstrand Conference: defining the need, the language, and a way forward.

Damage control resuscitation (DCR) is emerging as a standard practice in civilian and military trauma care. Primary objectives include resolution of immediate life threats followed by optimization of physiological status in the perioperative period. To accomplish this, DCR employs a unique hypotensive–hemostatic resuscitation strategy that avoids traditional crystalloid intravenous fluids in favor of early blood component use in ratios mimicking whole blood.

Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting: A critical appraisal of the medical literature and available alternatives.

BACKGROUND Hemorrhage remains the leading cause of preventable trauma-associated mortality. Interventions that improve prehospital hemorrhage control and resuscitation are needed. Tranexamic acid (TXA) has recently been shown to reduce mortality in trauma patients when administered upon hospital admission, and available data suggest that early dosing confers maximum benefit. Data regarding TXA implementation in prehospital trauma care and analyses of alternatives are lacking. This review examines the available evidence that would inform selection of hemostatic interventions to improve outcomes in prehospital trauma management as part of a broader strategy of “remote damage-control resuscitation” (RDCR). METHODS The medical literature available concerning both the safety and the efficacy of TXA and other hemostatic agents was reviewed. RESULTS TXA use in surgery was studied in 129 randomized controlled trials, and a meta-analysis was identified. More than 800,000 patients were followed up in large cohort study. In trauma, a large randomized controlled trial, the CRASH-2 study, recruited more than 20,000 patients, and two cohort studies studied more than 1,000 war casualties. In the prehospital setting, the US, French, British, and Israeli militaries as well as the British, Norwegian, and Israeli civilian ambulance services have implemented TXA use as part of RDCR policies. CONCLUSION Available data support the efficacy and the safety of TXA. High-level evidence supports its use in trauma and strongly suggests that its implementation in the prehospital setting offers a survival advantage to many patients, particularly when evacuation to surgical care may be delayed. TXA plays a central role in the development of RDCR strategies.

Implementation and execution of military forward resuscitation programs.

ABSTRACT Through necessity, military medicine has been the driver of medical innovation throughout history. The battlefield presents challenges, such as the requirement to provide care while under threat, resource limitation, and prolonged evacuation times, which must be overcome to improve casualty survival. Focus must also be placed on identifying the causes, and timing, of death within the battlefield. By doing so, military medical doctrine can be shaped, appropriate goals set, new concepts adopted, and relevant technologies investigated and implemented. The majority of battlefield casualties still die in the prehospital environment, before reaching a medical treatment facility, and hemorrhage remains the leading cause of potentially survivable death. Many countries have adopted policies that push damage control resuscitation forward into the prehospital setting, while understanding the need for timely medical evacuation. Although these policies vary according to country, the majority share many common principles. These include the need for early catastrophic hemorrhage control at point-of-wounding, judicious use of fluid resuscitation, use of blood products as far forward as possible, and early evacuation to a surgical facility. Some countries place medical providers with the ability, and resources, for advanced resuscitation with the forward fighting units (perhaps at company level), whereas others have established en route resuscitation capabilities. If we are to continue to improve battlefield casualty survival, we must continue to work together and learn from each other. We must also carry on working alongside our civilian colleagues so that the benefits of translational experience are not lost. This review describes several countries current military approaches to prehospital trauma care. These approaches, refined through a decade of experience, merit consideration for integration into civilian prehospital care practice.

The value of noninvasive measurement of the compensatory reserve index in monitoring and triage of patients experiencing minimal blood loss.

ABSTRACT Currently available triage and monitoring tools are often late to detect life-threatening clinically significant physiological aberrations and provide limited data in prioritizing bleeding patients for treatment and evacuation. The Compensatory Reserve Index (CRI) is a novel means of assessing physiologic reserve, shown to correlate with central blood volume loss under laboratory conditions. The purpose of this study was to compare the noninvasive CRI device with currently available vital signs in detecting blood loss. Study subjects were soldiers volunteering for blood donation (n = 230), and the control group was composed of soldiers who did not donate blood (n = 34). Data collected before and after blood donation were compared, receiver operator characteristic curves were generated after either donation or the appropriate time interval, and areas under the curves (AUCs) were compared. Compared with pre–blood loss, blood donation resulted in a mean reduction of systolic blood pressure by 3% (before, 123 mmHg; after, 119 mmHg; P < 0.01). The CRI demonstrated a 16% reduction (before, 0.74; after, 0.62; P < 0.01). Heart rate, diastolic blood pressure, and oxygen saturation remained unchanged. The AUC for change in CRI was 0.81, 0.56 for change in heart rate, 0.53 for change in systolic blood pressure, 0.55 and 0.58 for pulse pressure and shock index, respectively. The AUCs for detecting mild blood loss at a single measurement were 0.73 for heart rate, 0.60 for systolic blood pressure, 0.62 for diastolic blood pressure, 0.45 for pulse oximetry, and 0.84 for CRI. The CRI was better than standard indices in detecting mild blood loss. Single measurement of CRI may enable a more accurate triage, and CRI monitoring may allow for earlier detection of casualty deterioration.

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.

Prehospital intubation success rates among Israel Defense Forces providers: epidemiologic analysis and effect on doctrine.

BACKGROUND Advanced airway management is composed of a set of vital yet potentially difficult skills for the prehospital provider, with widely different clinical guidelines. In the military setting, there are few data available to inform guideline development. We reevaluated our advanced airway protocol in light of our registry data to determine if there were a preferred maximum number of endotracheal intubation (ETI) attempts; our success with cricothyroidotomy (CRIC) as a backup procedure; and whether there were cases where advanced airway interventions should possibly be avoided. METHODS This is a descriptive, registry-based study conducted using records of the Israel Defense Forces Trauma Registry at the research section of the Trauma and Combat Medicine Branch, Surgeon General’s Headquarters. We included all casualties for whom ETI was the initial advanced airway maneuver, and the number of ETI attempts was known. Descriptive statistics were used. RESULTS Of 5,553 casualties in the Israel Defense Forces Trauma Registry, 406 (7.3%) met the inclusion criteria. Successful ETI was performed in 317 casualties (78%) after any number of ETI attempts; an additional 46 (11%) underwent CRIC, and 43 (11%) had advanced airway efforts discontinued. ETI was successful in 45%, 36%, and 31% of the first, second, and third attempts, respectively, with an average of 28% success over all subsequent attempts. CRIC was successful in 43 (93%) of 46 casualties in whom it was attempted. Of the 43 casualties in whom advanced airway efforts were discontinued, 29 (67%) survived to hospital discharge. CONCLUSION After the first ETI attempt, success with subsequent attempts tended to fall, with minimal improvement in overall ETI success seen after the third attempt. Because CRIC exhibited excellent success as a backup airway modality, we advocate controlling the airway with CRIC if ETI efforts have failed after two or three attempts. We recommend that providers reevaluate whether definitive airway control is truly necessary before each attempt to control the airway. LEVEL OF EVIDENCE Care management, level IV.

Point-of-injury Use of Reconstituted Freeze Dried Plasma as a Resuscitative Fluid: A Special Report for Prehospital Trauma Care

Abstract : This special report describes the broader implications of prehospital fluid resuscitation in the context of what is the first reported case of point-of-injury use of reconstituted, lyophilized single-donor freeze dried plasma (FDP) as a resuscitative fluid. The Israeli Defense Force Medical Corps (IDF-MC) has deployed FDP as another step in the evolution of casualty care to bring damage-control resuscitation closer to the point of injury as part of the multidisciplinary efforts to improve trauma victims outcome.