An analysis of outcomes for pediatric trauma warm fresh whole blood recipients in Iraq and Afghanistan.

BACKGROUND: Whole blood therapy-which contains the ideal balance of components, and particularly fresh whole blood-has been shown to be beneficial in adult trauma. It remains unclear whether there is potential benefit in the pediatric population. STUDY DESIGN AND METHODS: This is a secondary analysis of previously published data analyzing pediatric casualties undergoing massive transfusion in the Department of Defense Trauma Registry. Pediatric patients with traumatic injury who were transfused at least one blood product were included in the analysis. We compared children who received component therapy exclusively to those who received any amount of warm fresh whole blood. RESULTS: Of the 3439 pediatric casualties within our dataset, 1244 were transfused at least one blood product within the first 24 h. There were 848 patients without severe head injury. Within this cohort, 23 children received warm fresh whole blood overall, 20 of whom did not have severe head injury. In an adjusted analysis, the odds ratio (95% confidence interval [CI]) for survival for warm fresh whole blood recipients was 2.86 (0.40-20.45). After removing children with severe brain injury, there was an independent association with improved survival for warm fresh whole blood recipients with an odds ratio (95% CI) of 58.63 (2.70-1272.67). DISCUSSION: Our data suggest that warm fresh whole blood may be associated with improved survival in children without severe head injury. Larger prospective studies are needed to assess the efficacy and safety of whole blood in children with severe traumatic bleeding.

Analysis of Prehospital Administration of Blood Products to Pediatric Casualties in Iraq and Afghanistan.

BACKGROUND: Hemorrhage is one of the leading causes of preventable death in both military and civilian trauma. Implementation of items such as tourniquets and hemostatic dressings are helpful in controlling hemorrhage and increasing the survival rate of casualties when such injuries occur. Prehospital blood transfusions are used to treat patients with severe injuries where the standard methods of hemorrhage control are not an effective form of treatment. There is limited research and no widely accepted protocol on pediatric prehospital blood transfusions. METHODS: We queried the Department of Defense Trauma Registry (DODTR) for all pediatric subjects admitted to U.S. and Coalition fixed-facility hospitals in Iraq and Afghanistan from January 2007 to January 2016. This is a secondary analysis of casualties that received blood products prehospital. RESULTS: From January 2007 through January 2016 there were 3439 pediatric casualties within the registry. Within this group, 22 casualties that received one or more blood product prehospital were identified. Children in the 10-14 years age (40%) group made up the largest proportion, 86% were male, almost all were injured by explosive (63%) or firearm (27%), and 77% survived to hospital discharge. The most frequently administered blood product was packed red cells (n = 17). Of the 22, 15 underwent massive transfusion within the first 24 hours of admission. CONCLUSIONS: Prehospital administration of blood products occurred infrequently within this pediatric dataset, but those that received blood were critically injured with most receiving a massive transfusion. Given the frequency with which medical personnel are carrying blood products in the prehospital, combat setting, guidelines specific to pediatric administration would be beneficial.

A Market Review of Available Airway Suction Technology.

INTRODUCTION: Airway injuries are the second leading cause of potentially survivable battlefield death and often require airway management strategies. Airway suction, the act of using negative pressure in a patient's upper airway, removes debris that can prevent respiration, decreases possible aspiration risks, and allows clearer viewing of the airway for intubation. The most important characteristics for a portable airway suction device for prehospital combat care are portability, strong suction, and ease of use. METHODS: This market review searched academic papers, military publications, Google searches, and Amazon to identify devices. The search included specific characteristics that would increase the likelihood that the devices would be suitable for battlefield use including weight, size, battery life, noise emission, canister size, tubing, and suction power. RESULTS: Sixty portable airway suction devices were resulted, 31 of which met inclusion criteria - 11 manually powered devices and 20 battery-operated devices. One type of manual suction pump was a bag-like design with a squeezable suction pump that was extremely lightweight but had limited suction capabilities (vacuum pressure of 100mmHg). Another type of manual suction pump had a trigger-like design which is pulled back to create suction with a firm collection canister that had increased suction capabilities (vacuum pressures of 188-600mmHg), though still less than the battery operated, and was slightly heavier (0.23-0.458kg). Battery-operated devices had increased suction capabilities and were easier to use, but they were larger and weighed more (1.18-11.0kg). CONCLUSION: Future research should work to lighten and debulk battery-operated suction devices with high suction performance.

A Scoping Review of Promising Alternative Blood Products for Prolonged Field Care.

Hemorrhage is the leading cause of potentially preventable death on the battlefield. Blood transfusions are used as treatment to restore circulating volume until the hemorrhage can be surgically controlled. Research has shown earlier transfusion of blood products has better casualty outcomes, so blood products have been pushed forward to the point of injury. Currently, there is a mixed use of blood components and whole blood in the prehospital setting-both of which have challenging supply chain requirements. Alternative blood products offer several potential advantages, as they are easier to mass produce, obviating the need for donor recruitment. They also have improved shelf-life stability, potentially remove cold-chain storage, and even cross-matching requirements. In this limited review, we sought to provide a narrative review of current promising developments including hemoglobin-based oxygen carriers, polyhemoglobin, platelet like cells, dried plasma, liquid plasma, fibrinogen concentrates, enzyme concentrates, nanoparticles, and perfluorocarbon-based artificial oxygen carriers.

Development of Data-Driven Triage Systems for Identifying Mortally Wounded Casualties-Implications for Future Large-Scale Combat Operations.

BACKGROUND: Uncontested air movement and advances for medical care of combat casualties have resulted in a decreased case fatality rate. However, in future large-scale combat operations, the military has established a plan for multidomain operations to defeat near-peer adversaries. Prolonged casualty care and mass casualty scenarios will become more prevalent. Prehospital friendly scoring systems such as the shock index (SI) and revised trauma score (RTS) may provide useful triage data. Development of accurate, data-driven, triage systems will be key to optimize management of resources, care, and transport of combat casualties. METHODS: We included data from the Department of Defense Trauma Registry between 01 January 2007 to 17 March 2020. Data comprised of adult US military or coalition service members for analysis as the baseline cohort, and those who died within 24 hours were included in the early death cohort. We performed statistical analysis on demographics and injury data, SI and RTS to measure the receiver operating characteristics (ROC) of each value to predict early death. RESULTS: The early death cohort had a significantly higher injury severity score (25 vs. 5) and a higher percentage of serious injuries in every body region than the baseline cohort. The early death cohort sustained serious injuries to the head and neck at a rate five times that of the baseline cohort (43.4% vs 8.1%) with odds ratio (OR) of death 8.0 (95% confidence interval 5.7-11.1) followed by skin (13.6% versus 1.9%) with an OR of 6.3 (95% CI 3.8-10.3). The mean SI was 1.21 versus 0.80. The revised trauma score (RTS) was 4.18 versus 7.34. The RTS had a higher area under the receiver operating characteristic (0.896 versus 0.716 for SI). CONCLUSIONS: Serious injuries to the head and skin were most strongly associated with death within the first 24 hours. The RTS appears to be a more accurate tool than SI alone for assessing injury mortality. Military medical personnel should consider these factors when triaging casualties during future conflicts in resource limited settings with delayed evacuation.

An Analysis of Conflicts Across Role 1 Guidelines.

INTRODUCTION: Role 1 care is vital to patient survival and includes many echelons of care from point-of-injury first aid to medical attention at battalion aid stations. Many guidelines are written for Role 1 care providers to optimize care for different scenarios. Differences in the guidelines lead to confusion and discrepancies between the types of treatment medical care providers provide. Although the guidelines were written for different areas of care, uniformity between the guidelines is needed and will lead to a reduced mortality rate. MATERIALS AND METHODS: It was determined that the Tactical Combat Casualty Care Guidelines, Prolonged Field Care Guidelines, Joint Trauma System Clinical Practice Guidelines, and Standard Medical Operating Guidelines from medical evacuation were the military medical guidelines most relevant to Role 1 care. These Guidelines were compared side by side to determine the differences between them. RESULTS: Although the guidelines were largely similar, many major differences were found between them. Our online tables contain large inconsistences between guidelines including direct contradictions in conversion of junctional tourniquets and the administration of tranexamic acid. CONCLUSIONS: Role 1 care is vital to patient survival, including care from point of injury to battalion aid stations, but the guidelines available to instruct this care and the guidance on which personnel should provide this care are conflicting. This lack of clarity and consistency may adversely impact treatment outcomes. The reduction or elimination of conflicting information across the various guidelines, augmentation of guidance for pediatric care, more specific guidance for unique levels of care, and clearer delineation of the Role 1 phases of care (as well as which guidelines are most appropriate to each) should be considered as urgent priorities within the military medical community.

Incidence of Expired Blood Product Use in the US Central Command Theater of Operations.

OBJECTIVE: Introduction: During multi-domain combat operations, logistical constraints may compel forward medical personnel to decide whether to use expired blood products. The incidence of expired blood product usage in recent conflicts is unknown. METHODS: We queried the Armed Services Blood Program (ASBP) database of all blood administered in theater from 2002-2019. We categorized any administration of blood product with a transfusion date of 1-30 days after the expiration date for this analysis. We excluded any documented transfusions more than 30 days after the expiration date as likely represents clerical error based on study team experience. RESULTS: There were 1,491 (0.4% of the total transfusion dataset) units that met inclusion for this analysis. Of the 1,491, 86% (n=1,278 transfusions) will occur within 1-3 days post-expiration. These 1,491 units were transfused into 741 patients. The majority of expired blood product recipients were male (87%). Afghans were most frequent (46%), followed by US forces (22%) with most occurring during Operation Enduring Freedom (64%). Trauma was the most common mechanism of injury for these patients (70%). The most common blood type transfused to recipients was O positive (28%). The most frequently transfused expired unit was red blood cells (n=899), followed by platelets (n=299), followed by whole blood (n=152). CONCLUSIONS: Expired red blood cell and platelet use suggests a need for better methods for extending the lifespan of whole blood and further development of longer stability cold-stored platelets to meet the needs of our end-users. Our data arises from mature theaters during counterinsurgency operations. The incidence of transfusion of expired blood products may increase in future multi-domain operations where medical personnel are likely to operate under more resource constrained settings.