Warren C. Dorlac

Complications After Fasciotomy Revision and Delayed Compartment Release in Combat Patients

BACKGROUND Incomplete or delayed fasciotomies are associated with muscle necrosis and death in civilian trauma. Combat explosions severely damage tissue and distort normal anatomy making fasciotomies challenging. Rapid air evacuation may delay treatment of patients with evolving extremity compartment syndrome. We investigated the impact of fasciotomy revision and delayed compartment release on combat casualties after air evacuation. METHODS A retrospective review was performed of combat casualties who underwent fasciotomies in Iraq, Afghanistan, or at Landstuhl Regional Medical Center between January 1, 2005 and August 31, 2006. Outcomes were rates of muscle excision, major amputation, and mortality. RESULTS A total of 336 patients underwent 643 fasciotomies. Most were to the lower leg (49%) and forearm (23%). Patients who underwent a fasciotomy revision had higher rates of muscle excision (35% vs. 9%, p < 0.01) and mortality (20% vs. 6%, p < 0.01) than those who did not receive a revision. The anterior and deep compartments of the lower leg were the most commonly unopened. Patients who underwent fasciotomy after evacuation had higher rates of muscle excision (25% vs. 11%), amputation (31 vs. 15%), and mortality (19% vs. 5%) than patients who received their fasciotomies in the combat theater (p < 0.01). Patients who underwent revisions or delayed fasciotomies had higher Injury Severity Score and larger burns as well as lower systolic blood pressure, acidosis, and more pressor use during air evacuation. These patients also received more blood products at Landstuhl Regional Medical Center. CONCLUSION Fasciotomy revision was associated with a fourfold increase in mortality. The most common revision procedures were extension of fascial incisions and opening new compartments. The most commonly unopened compartment was the anterior compartment of the lower leg. Patients who underwent delayed fasciotomies had twice the rate of major amputation and a threefold higher mortality.

East Practice Management Guidelines Work Group: update to practice management guidelines for prophylactic antibiotic use in open fractures.

STATEMENT OF THE PROBLEMAn open fracture is defined as one in which the fracture fragments communicate with the environment through a break in the skin. The presence of an open fracture either isolated or as part of a multiple injury complex increases the risk of infection and soft tissue complicati

Prevention of infections associated with combat-related extremity injuries

During combat operations, extremities continue to be the most common sites of injury with associated high rates of infectious complications. Overall, ∼ 15% of patients with extremity injuries develop osteomyelitis, and ∼ 17% of those infections relapse or recur. The bacteria infecting these wounds have included multidrug-resistant bacteria such as Acinetobacter baumannii, Pseudomonas aeruginosa, extended-spectrum β-lactamase-producing Klebsiella species and Escherichia coli, and methicillin-resistant Staphylococcus aureus. The goals of extremity injury care are to prevent infection, promote fracture healing, and restore function. In this review, we use a systematic assessment of military and civilian extremity trauma data to provide evidence-based recommendations for the varying management strategies to care for combat-related extremity injuries to decrease infection rates. We emphasize postinjury antimicrobial therapy, debridement and irrigation, and surgical wound management including addressing ongoing areas of controversy and needed research. In addition, we address adjuvants that are increasingly being examined, including local antimicrobial therapy, flap closure, oxygen therapy, negative pressure wound therapy, and wound effluent characterization. This evidence-based medicine review was produced to support the Guidelines for the Prevention of Infections Associated With Combat-Related Injuries: 2011 Update contained in this supplement of Journal of Trauma.

Guidelines for the prevention of infections associated with combat-related injuries: 2011 update endorsed by the infectious diseases society of America and the surgical infection society

Despite advances in resuscitation and surgical management of combat wounds, infection remains a concerning and potentially preventable complication of combat-related injuries. Interventions currently used to prevent these infections have not been either clearly defined or subjected to rigorous clinical trials. Current infection prevention measures and wound management practices are derived from retrospective review of wartime experiences, from civilian trauma data, and from in vitro and animal data. This update to the guidelines published in 2008 incorporates evidence that has become available since 2007. These guidelines focus on care provided within hours to days of injury, chiefly within the combat zone, to those combat-injured patients with open wounds or burns. New in this update are a consolidation of antimicrobial agent recommendations to a backbone of high-dose cefazolin with or without metronidazole for most postinjury indications, and recommendations for redosing of antimicrobial agents, for use of negative pressure wound therapy, and for oxygen supplementation in flight.

Joint Theater Trauma System implementation of burn resuscitation guidelines improves outcomes in severely burned military casualties.

BACKGROUND Between March 2003 and June 2007, our burn center received 594 casualties from the conflicts in Iraq and Afghanistan. Ongoing acute burn resuscitation as severely burned casualties are evacuated over continents is very challenging. To help standardize care, burn resuscitation guidelines (BRG) were devised along with a burn flow sheet (BFS) and disseminated via the new operational Joint Theater Trauma System to assist deployed providers. METHODS After the BRG was implemented in January 2006, BRF data were prospectively collected in consecutive military casualties with >30% total body surface area (TBSA) burns (BRG Group). Baseline demographic data and fluid requirements for the first 24 hours of the burn resuscitation were collected from the BFS. Percentage full thickness TBSA burns, presence of inhalation injury, injury severity score, resuscitation-related abdominal compartment syndrome, and mortality were collected from our database. Individual charts were reviewed to determine the presence of extremity fasciotomies and myonecrosis. These results were compared with consecutive military casualties admitted during the 2-year- period before the system-wide implementation of the BRG (control group). RESULTS One hundred eighteen military casualties with burns >30% TBSA were admitted between January 2003 and June 2007, with n = 56 in the BRG group and n = 62 in the control group. The groups were different in age, but similar in %TBSA, %full thickness, presence of inhalation injury, and injury severity score. There was no difference in the rate of extremity fasciotomies or the incidence of myonecrosis between groups. CONCLUSIONS The composite endpoint of abdominal compartment syndrome and mortality was significantly lower in the BRG group compared with the control group (p = 0.03). Implementation of the BRG and system-wide standardization of burn resuscitation improved outcomes in severely burned patients. Utilization of the joint theater trauma system to implement system-wide guidelines is effective and can help improve outcomes.

Tranexamic Acid and Trauma: Current Status and Knowledge Gaps with Recommended Research Priorities

ABSTRACT A recent large civilian randomized controlled trial on the use of tranexamic acid (TXA) for trauma reported important survival benefits. Subsequently, successful use of TXA for combat casualties in Afghanistan was also reported. As a result of these promising studies, there has been growing interest in the use of TXA for trauma. Potential adverse effects of TXA have also been reported. A US Department of Defense committee conducted a review and assessment of knowledge gaps and research requirements regarding the use of TXA for the treatment of casualties that have experienced traumatic hemorrhage. We present identified knowledge gaps and associated research priorities. We believe that important knowledge gaps exist and that a targeted, prioritized research effort will contribute to the refinement of practice guidelines over time.

Impact of critical care-trained flight paramedics on casualty survival during helicopter evacuation in the current war in Afghanistan.

BACKGROUND The US Army pioneered medical evacuation (MEDEVAC) by helicopter, yet its system remains essentially unchanged since the Vietnam era. Care is provided by a single combat medic credentialed at the Emergency Medical Technician – Basic level. Treatment protocols, documentation, medical direction, and quality improvement processes are not standardized and vary significantly across US Army helicopter evacuation units. This is in contrast to helicopter emergency medical services that operate within the United States. Current civilian helicopter evacuation platforms are routinely staffed by critical care–trained flight paramedics (CCFP) or comparably trained flight nurses who operate under trained EMS physician medical direction using formalized protocols, standardized patient care documentation, and rigorous quality improvement processes. This study compares mortality of patients with injury from trauma between the US Army’s standard helicopter evacuation system staffed with medics at the Emergency Medical Technician – Basic level (standard MEDEVAC) and one staffed with experienced CCFP using adopted civilian helicopter emergency medical services practices. METHODS This is a retrospective study of a natural experiment. Using data from the Joint Theater Trauma Registry, 48-hour mortality for severely injured patients (injury severity score ≥ 16) was compared between patients transported by standard MEDEVAC units and CCFP air ambulance units. RESULTS The 48-hour mortality for the CCFP-treated patients was 8% compared to 15% for the standard MEDEVAC patients. After adjustment for covariates, the CCFP system was associated with a 66% lower estimated risk of 48-hour mortality compared to the standard MEDEVAC system. CONCLUSIONS These findings demonstrate that using an air ambulance system based on modern civilian helicopter EMS practice was associated with a lower estimated risk of 48-hour mortality among severely injured patients in a combat setting. LEVEL OF EVIDENCE Therapeutic study, level II.

Air transport of patients with severe lung injury: Development and utilization of the acute lung rescue team

BACKGROUND Critical Care Air Transport Teams (CCATTs) are an integral component of modern casualty care, allowing early transport of critically ill and injured patients. Aeromedical evacuation of patients with significant pulmonary impairment is sometimes beyond the scope of CCATT because of limitations of the transport ventilator and potential for further respiratory deterioration in flight. The Acute Lung Rescue Team (ALRT) was developed to facilitate transport of these patients out of the combat theater. METHODS The United States TRANSCOM Regulation and Command/Control Evacuation System and the United States Army Institute of Surgical Research Joint Theater Trauma Registry databases were reviewed for all critical patients transported out of theater between November 2005 and March 2007. Patient demographics, diagnosis, and clinical history were abstracted and ALRT patients were compared with CCATT patients. RESULTS The ALRT was activated for 11 patients during the study period. Five patients were transported as a result of these activations. Trauma-related diagnoses were responsible for 82% of these requests. ALRT missions comprised 0.6% of all critical patient movements out of the combat theater and 1% of ventilator transports. Average FIO2 was 0.92 +/- 0.11 for ALRT patients and 0.53 +/- 0.14 for CCATT patients (p = 0.005). ALRT patients required a mean positive end expiratory pressure of 19.0 cm H2O +/- 2.2 cm H2O compared with 6.5 cm H2O +/- 2.4 cm H2O in the CCATT group (p = 0.002). CONCLUSIONS Lung injury in the combat theater severe enough to exceed the capability of CCATT transport is uncommon. Patients for whom ALRT was activated had significantly higher positive end expiratory pressure and FIO2 than those transported by CCATT. One-fourth of patients for whom ALRT was considered died before the team could be launched; transport may have been a futile consideration in these patients. Patients with even severe acute respiratory distress syndrome can be successfully transported by experienced, equipped specialty teams.

Resuscitation with fresh whole blood ameliorates the inflammatory response after hemorrhagic shock.

BACKGROUND Hemorrhagic shock is the leading cause of potentially preventable death after traumatic injury. Hemorrhage and subsequent resuscitation may result in a dysfunctional systemic inflammatory response and multisystem organ failure, leading to delayed mortality. Clinical evidence supports improved survival and reduced morbidity when fresh blood products are used as resuscitation strategies. We hypothesized that the transfusion of fresh whole blood (FWB) attenuates systemic inflammation and reduces organ injury when compared with conventional crystalloid resuscitation after hemorrhagic shock. METHODS Male mice underwent femoral artery cannulation and hemorrhage to a systolic blood pressure of 25 mm Hg +/- 5 mm Hg. After 60 minutes, the mice were resuscitated with either FWB or lactated Ringers solution (LR). Mice were decannulated and killed at intervals for tissue histology, serum cytokine analysis, and vascular permeability studies. Separate groups of mice were followed for survival studies. RESULTS When compared with FWB, mice resuscitated with LR required increased resuscitation fluid volume to reach goal systolic blood pressure. When compared with sham or FWB-resuscitated mice, LR resuscitation resulted in increased serum cytokine levels of macrophage inflammatory protein-1alpha, interleukin-6, interleukin-10, macrophage-derived chemokine, KC, and granulocyte macrophage colony stimulating factor as well as increased lung injury and pulmonary capillary permeability. No survival differences were seen between animals resuscitated with LR or FWB. CONCLUSIONS Resuscitation with LR results in increased systemic inflammation, vascular permeability, and lung injury after hemorrhagic shock. Resuscitation with FWB attenuates the inflammation and lung injury seen with crystalloid resuscitation. These findings suggest that resuscitation strategies using fresh blood products potentially reduce systemic inflammation and organ injury after hemorrhagic shock.

A review of the first 10 years of critical care aeromedical transport during operation iraqi freedom and operation enduring freedom: the importance of evacuation timing.

IMPORTANCE Advances in the care of the injured patient are perhaps the only benefit of military conflict. One of the unique aspects of the military medical care system that emerged during Operation Iraqi Freedom and Operation Enduring Freedom has been the opportunity to apply existing civilian trauma system standards to the provision of combat casualty care across an evolving theater of operations. OBJECTIVES To identify differences in mortality for soldiers undergoing early and rapid evacuation from the combat theater and to evaluate the capabilities of the Critical Care Air Transport Team (CCATT) and Joint Theater Trauma Registry databases to provide adequate data to support future initiatives for improvement of performance. DESIGN, SETTING, AND PARTICIPANTS Retrospective review of CCATT records and the Joint Theater Trauma Registry from September 11, 2001, to December 31, 2010, for the in-theater military medicine health system, including centers in Iraq, Afghanistan, and Germany. Of 2899 CCATT transport records, those for 975 individuals had all the required data elements. EXPOSURE Rapid evacuation by the CCATT. MAIN OUTCOMES AND MEASURES Survival as a function of time from injury to arrival at the role IV facility at Landstuhl Regional Medical Center. RESULTS The patient cohort demonstrated a mean Injury Severity Score of 23.7 and an overall 30-day mortality of 2.1%. Mortality en route was less than 0.02%. Statistically significant differences between survivors and decedents with respect to the Injury Severity Score (mean [SD], 23.4 [12.4] vs 37.7 [16.5]; P < .001), cumulative volume of blood transfused among the patients in each group who received a transfusion (P < .001), worst base deficit (mean [SD], -3.4 [5.0] vs -7.8 [6.9]; P = .02), and worst international normalized ratio (median [interquartile range], 1.2 [1.0-1.4] vs 1.4 [1.1-2.2]; P = .03) were observed. We found no statistically significant difference between survivors and decedents with respect to time from injury to arrival at definitive care. CONCLUSIONS AND RELEVANCE Rapid movement of critically injured casualties within hours of wounding appears to be effective, with a minimal mortality incurred during movement and overall 30-day mortality. We found no association between the duration of time from wounding to arrival at Landstuhl Regional Medical Center with respect to mortality.