Military medical research in the IDF: an array of fields and interests.

BACKGROUND: War is as old as history. Some may say it is older. The first Biblical war, dated 1880-1875 BCE, is depicted in the book of Genesis between nine kings in the vicinity of the Jordan river near Jericho. By the end of the war, Abraham (Abram) gets involved in saving his nephew Lot. In addition to war, military medicine also has its roots in historical times. Hippocrates (460-377 BCE), the father of medicine, derived his medical knowledge from the battlefield, and Sushruta [1], the father of plastic surgery, mentioned the physician's preventive role in noting environmental hazards: "A common practice of the enemy is to poison the wells on the roadside, the articles of food, the shades of trees, and the fuel and forage for cattle; hence, it is incumbent on a physician marching with the troops to inspect, examine, and purify these before using any of them, in case they are poisoned." The Greeks stated new ideas of military health, pointing to fitness promotion, gymnastics, and healthy diets to prevent illness. Over the centuries, from Alexander the Great to Napoleon's army and wars in the 20th century, military conflicts have led to the death of hundreds of millions of people from trauma and war-related disease. Amazingly analyses of the 18th and 19th centuries have shown that 80% of the soldiers died from disease, and historians and military personnel agree that during armed conflicts in known history, only a minority of soldiers perished by the sword. In Israel, the Israel Defense Forces-Medical Corps (IDF-MC) holds a unique position embedded in military and civilian national medicine. All medical personnel (e.g., physicians, nurses, technicians, veterinarians) who work in the IDF-MC receive their diplomas from civilian universities, train in civilian hospitals, and continue to practice in the national health system. The majority of these professionals continue to work in different civilian medical platforms in Israel after finishing their mandatory service. The IDF-MC's primary mission is to provide optimal medical care to IDF soldiers at all times (including wartime), to prevent disease and promote health, advance military medicine, and aid the civilian sector as ordered by the Government of Israel. In this special issue of Israel Medical Association Journal (IMAJ) is to expose readers to the continuous efforts of the IDF-MC to fulfill its mission by promoting research in multiple medical fields, including trauma, ambulatory care, health administration. In addition, in this issue of IMAJ, authors discuss the unique collaboration with the civilian system during the coronavirus disease 2019 (COVID-19) pandemic. Trauma and trauma-related injuries are the main focus of military medical research. Ben-Avi and colleagues [2] described outcomes of emergent exploratory thoracotomies on military casualties and addresses parameters that may impact the survival of these casualties. Minervini [3] further discussed the issue. Bez et al. [4] researched the impact of isolated versus non-isolated traumatic brain injuries on injury identification and decision-making by care providers in austere scenarios. Tsur and co-authors [5] described the characteristics of a unique type of terror attack: vehicle ramming. Additional examples of treatments provided in the military prehospital arena were analyzed by Nakar and colleagues [6] who discussed how to assess pain medications administered to trauma casualties in the past two decades by IDF-MC care providers. Rittblat et al. [7] further described the use of freeze-dried plasma, a blood component used in the prehospital arena and administered via intraosseous vascular access. The IDF-MC is a continuously changing organization emphasizing the adoption of advanced technologies and devices. Chen et al. [8] presented a blinded study on the use of point-of-care ultrasound and remote telementored ultrasound by inexperienced operators, and Sorkin et al. [9] described the BladeShield 101: a novel device for the battlefield designed to continuously measure vital signs and medical treatment provided and to transfer data through roles of care. In this special issue of IMAJ, authors also discusse gender-related aspects at the core of medical treatment. Segal et al. [10] examined whether missed injuries were related to the medical provider's gender, while Gelikas et al. [11] assessed whether treatment with analgesia was associated with casualty gender in the military prehospital trauma setting Over the past two and a half years, the COVID-19 pandemic has been a significant part of our lives. During these years, medical systems and teams throughout Israel and around the world struggled to adapt to this new disease and save lives fighting the pandemic. Geva et al. [12] and Shental et al. [13] discussed the impact of COVID-19 on the IDF medical system, lessons learned during the outbreak, and effects of different diseases during these times on medical treatment provided by the IDF to soldiers.

Opioid sparing effect of ketamine in military prehospital pain management-A retrospective study.

BACKGROUND: Opioids are the most commonly used analgesics in acute trauma, but are limited by slow onset and significant adverse effects. Ketamine is an effective and widely used analgesic. This study was aimed to evaluate the effectiveness and opioid-sparing effects of ketamine when used in prehospital military trauma setting. METHODS: A retrospective analysis of a prehospital military trauma registry between 2014 and 2020. Inclusion criteria were 16 years or older, two or more documented pain assessments, at least one indicating severe pain, and administration of opioids and/or low-dose ketamine. Joint hypothesis testing was used to compare casualties who received opioids only to those who received ketamine on outcomes of pain score reduction and opioid consumption. RESULTS: Overall, 382 casualties were included. Ninety-one (24%) received ketamine (21 as a single analgesic), with a mean dose of 29 mg (standard deviation, 11). Mean reduction in pain scores (on an 11-point scale) was not significantly different; 4.3-point (2.8) reduction in the ketamine group and 3.7 points (2.4) in the opioid-only group ( p = 0.095). Casualties in the ketamine group received a median of 10 mg (interquartile range, 3.5-25) of morphine equivalents (MEs) compared with a median of 20 ME (10, 20) in the opioid-only group. In a multivariable multinomial logistic regression, casualties in the ketamine group were significantly more likely to receive a low (1-10 ME) rather than a medium (11-20 ME) dose of opioids compared with the opioid-only group (odds ratio, 0.032; 95% confidence interval, 0.14-0.75). CONCLUSION: The use of ketamine in the prehospital military setting as part of a pain management protocol was associated with a low rather than medium dose of opioids in a multivariable analysis, while the mean reduction in pain scores was not significantly different between groups. Using ketamine as a first-line agent may further reduce opioid consumption with a similar analgesic effect. LEVEL OF EVIDENCE: Therapeutic/care management; Level IV.

Combat-related ocular injuries in the Israel Defense Forces during the years 2013 to 2019.

BACKGROUND: Ocular injuries account for up to 13% of battle injuries, despite the implementation of advanced protective eyewear (PE). The aim of this study was to describe the extent of ocular injuries over the last years among Israel Defense Forces soldiers and to examine the change in PE policy introduced in 2013 and the effect of a high-intensity conflict on ocular injury characteristics. METHODS: This retrospective registry-based analysis derived data from the Israel Defense Forces Trauma Registry and included soldiers who sustained combat-related ocular injuries between the years 2013 and 2019. Demographic data and injury characteristics of casualties, as well as information regarding the use of PE, were collected and analyzed. RESULTS: A total of 2,312 military casualties were available for this study; the incidence of combat-related ocular injuries was 8.9% (n = 113). Ocular injuries occurred among male soldiers (98.2%) with a mean ± SD age of 22.7 ± 4.6 years; mechanism of injury was penetrating in 59.3% of the casualties and blunt in 22.1% of the casualties, ocular injury was isolated in 51.3% of the casualties, and others sustained concomitant injuries including head (32.7%), upper extremity injury (17.7%), lower extremity (15.9%), torso (8.0%), neck (6.2%), and other (5.9%) injuries. Ocular injuries rate was similar among casualties who used PE (11.2%) and those who did not use PE (13.0%) while injured (p = 0.596). Rate of open globe injuries was 9.1% in casualties who used PE and 39.5% (p = 0.002) in casualties who did not. CONCLUSION: Eye protection may significantly reduce ocular injuries severity. Education of the combatants on the use of PE and guidance of medical teams on proper assessment, initial treatment, and rapid evacuation of casualties are needed to improve visual outcomes of the casualties further. LEVEL OF EVIDENCE: Epidemiological study, level IV.

Pain management for casualties receiving lifesaving interventions in the prehospital scenario: Raising awareness of our human nature.

BACKGROUND: Lifesaving interventions (LSIs) are the hallmark of medical care in trauma casualties, reducing mortality and morbidity. Analgesia is another essential treatment, which has been shown to improve outcomes and decrease long-term complications. However, oligoanalgesia is common, and information regarding its relation to the performance of LSIs is scarce. The purpose of this study was to assess the relation between the performance of LSIs and analgesia administration in the prehospital environment. METHODS: A retrospective database-based study was performed, including all trauma casualties treated by Israeli Defense Forces physicians and paramedics during 2006 to 2017 and admitted to hospitals participating in the Israeli National Trauma Registry. Included LSIs were tourniquet application, administration of tranexamic acid and freeze-dried plasma, and administration of chest decompression. Casualties treated with endotracheal intubation or cricothyroidotomy were excluded. RESULTS: In the multivariable logistic regression analysis, LSIs were associated with prehospital analgesia administration (odds ratio [OR], 3.59; confidence interval [CI], 2.56-5.08; p < 0.001). When assessing for the different LSIs, tourniquet application (OR, 2.83; CI, 1.89-4.27; p < 0.001) and tranexamic acid administration (OR, 4.307; CI, 2.42-8.04; p < 0.001) were associated with prehospital analgesia administration. CONCLUSION: A positive association exists between performance of LSIs and administration of analgesia in the prehospital environment. Possible explanations may include cognitive and emotional biases affecting casualty care providers. LEVEL OF EVIDENCE: Retrospective study, level IV.

Trends in prehospital pain management following the introduction of new clinical practice guidelines.

BACKGROUND: Early pain treatment following injury has been shown to improve long-term outcomes, while untreated pain can facilitate higher posttraumatic stress disorder rates and worsen outcomes. Nonetheless, trauma casualties frequently receive inadequate analgesia. In June 2013, a new clinical practice guideline (CPG) regarding pain management was introduced in the Israel Defense Forces (IDF) Medical Corps, recommending oral transmucosal fentanyl citrate (OTFC) and low-dose intravenous (IV)/intramuscular ketamine. The purpose of this study was to examine trends in prehospital pain management in the IDF. METHODS: All cases documented in the IDF trauma registry between 2008 and 2020 were examined. This study compared casualty parameters before and after the introduction of analgesia CPG in 2013. Parameters compared included demographics, injury parameters, treatment modalities, and types of analgesia provided. RESULT: Overall, 5,653 casualties were included in our study. During the 6 years before the introduction of the CPG, 289 (26.7%) of 1,084 casualties received an analgesic treatment, compared with 1,578 (34.5%) of 4,569 casualties during the 7 years following (p < 0.001). Since its introduction, OTFC was administered to 41.8% of all casualties who received analgesia and became the most used analgesic drug in 2020 (61.1% of casualties receiving analgesia). The rate of IV morphine significantly decreased after 2013 (22.6-16%, p < 0.001). CONCLUSION: Pain management has become more common in trauma patients' prehospital care in the IDF in recent years. There has been a significant increase in analgesia administration, with the increased use of OTFC, along with a significant reduction in the use of IV morphine. These results may be attributed to introducing a pain management CPG and implementing OTFC among medical teams. The perception of OTFC as a safe user-friendly analgesic may have contributed to its use by medical providers, increasing analgesia rates overall. LEVEL OF EVIDENCE: Therapeutic/care management, level III.

Trends in combat casualty care following the publication of clinical practice guidelines.

BACKGROUND: The current study explores the trends in the application of combat casualty care following the publication of clinical practice guidelines (CPGs) in five domains for 13 years. METHODS: The Israel Defense Forces Trauma Registry was used to assess practice and adherence to guidelines in five domains: (a) crystalloid transfusions, (b) tranexamic acid use, (c) freeze-dried plasma use, (d) chest decompression, and (e) airway management. All patients injured between January 2006 and December 2018 were included in the analysis. Trends were analyzed and presented monthly using linear regression and were compared using the Chow test. RESULTS: The mean ± SD crystalloid volume transfused decreased from 1,179 ± 653 mL in 2006 to 466 ± 202 mL in 2018 (B = 0.016, 0.006-0.044). The proportion of patients with an indication treated with tranexamic acid dropped from 8% (238 of 2,979 patients) to 2.5% (60 of 2,356 patients) following the stricter guideline's publication. Freeze-dried plasma administration in indicated casualties rose from 12.5% in 2013 to 48% in 2018 (B = 1.63, 1.3-2.05). The overall proportion of casualties undergoing chest decompression rose from 1% (61 of 6,036 casualties) to 1.5% (155 of 10,493 casualties) following the release of a new CPG in 2012 (p = 0.013). There were no significant trends in intubation ratios before (B = 0.987, 0.953-1.02) or after 2012 (B = 10.2, 0.996-1.05). CONCLUSION: Some aspects demonstrate the desired trends in response to new CPGs; in others, initial improvement is achieved but followed by stagnation. In some medical care aspects, completely unexpected and undesirable trends are observed. Every change and update in CPGs should be based on reliable data. The effect of every change must be monitored carefully to ensure adequate adherence to lifesaving guidelines. LEVEL OF EVIDENCE: Epidemiological study, level IV.

Inclusion of extranodal extension in the lymph node classification of cutaneous squamous cell carcinoma of the head and neck.

BACKGROUND: The prognostic performance of the recently updated American Joint Committee on Cancer lymph node classification of cutaneous head and neck squamous cell carcinoma (HNSCC) has not been validated. The objective of this study was to assess the prognostic role of extranodal extension (ENE) in cutaneous HNSCC. METHODS: This was a retrospective analysis of 1258 patients with cutaneous HNSCC who underwent surgery with or without adjuvant therapy between 1995 and 2019 at The University of Texas MD Anderson Cancer Center. The primary outcome was disease-specific survival (DSS). Local, regional, and distant metastases-free survival were secondary outcomes. Recursive partitioning analysis (RPA) and a Cox proportional hazards regression model were used to assess the fitness of staging models. RESULTS: No significant differences in 5-year DSS were observed between patients with pathologic lymph node-negative (pN0) disease (67.4%) and those with pN-positive/ENE-negative disease (68.2%; hazard ratio, 1.02; 95% CI, 0.61-1.79) or between patients with pN-positive/ENE-negative disease and those with pN-positive/ENE-positive disease (52.7%; hazard ratio, 0.57; 95% CI, 0.31-1.01). The RPA-derived model achieved better stratification between high-risk patients (category III, ENE-positive with >2 positive lymph nodes) and low-risk patients (category I, pN0; category II, ENE-positive/pN1 and ENE-negative with >2 positive lymph nodes). The performance of the RPA-derived model was better than that of the pathologic TNM classification (Akaike information criterion score, 1167 compared with 1176; Bayesian information criterion score, 1175 compared with 1195). CONCLUSIONS: The number of metastatic lymph nodes and the presence of ENE are independent prognostic factors for DSS in cutaneous HNSCC, and incorporation of these factors in staging systems improves the performance of the American Joint Committee on Cancer lymph node classification.

Integrating depth of invasion in T classification improves the prognostic performance of the American Joint Committee on Cancer primary tumor staging system for cutaneous squamous cell carcinoma of the head and neck.

BACKGROUND: The last revision of the American Joint Committee on Cancer (AJCC) Cancer Staging Manual included a specific system for cutaneous squamous cell carcinoma (CSCC) of the head and neck. Here, we assessed the prognostic performance of six candidate modified T-classification models in head and neck CSCC patients. METHODS: Analysis of 916 patients with head and neck CSCC given treatment with curative intent at The University of Texas MD Anderson Cancer Center between 1995 and 2019 was performed. The main outcome was disease-specific survival (DSS), and the impact of depth of invasion (DOI) was analyzed using multivariable regression models. Candidate models were developed using the optimal DOI cut points for each AJCC T classification based on goodness of fit of the model and the simplicity of the model. Staging systems were compared using Harrell's concordance index. RESULTS: Median age was 70 years (range, 19-97years) and median follow-up time of 22 months (range, 1-250months). The median DOI was 6.0 mm (range, 0.1-70.0 mm). The five-year DSS rate was 80.7% (95%CI, 77.4-83.7%). We found significant association between DOI (hazard ratio, 1.21 [95%CI: 1.01-1.43]) and DSS on multivariable analysis. Based on a low Akaike information criterion score, improvement in the concordance index, and Kaplan-Meier curves, model 6 surpassed the AJCC staging system. CONCLUSIONS: Incorporation of DOI in the current AJCC staging system improves discrimination of T classifications in head and neck CSCC patients. LAY SUMMARY: The current staging system for head and neck cutaneous squamous cell carcinoma demonstrates wide prognostic variability and provides suboptimal risk stratification. Incorporation of depth of invasion in the T-classification system improves risk prediction and patient counseling. PRECIS: We propose improved head and neck cutaneous squamous cell carcinoma T staging that will include depth of invasion and should be considered in future versions of the American Joint Committee on Cancer after external validation.

The Israel Defense Forces Trauma Registry: 22 years of point-of-injury data.

BACKGROUND: Trauma is the leading cause of death among casualties between 1 and 44 years. A large proportion of trauma deaths occurs even before arriving at a medical facility. The paucity of prehospital data is a major reason for the lagging development of prehospital trauma care research. This study aims to describe the Israel Defense Forces Prehopistal Trauma Registry, the steps taken to improve data collection and quality, the resulting trends, and the registry's contribution to policymaking. METHODS: This study explores the quantity and quality of point of injury and prehospital data in the registry between the years 1997 and 2018. We assessed the number of recorded casualties per year, casualties characteristics, and documentation variables in the registry, with a specific focus on documentation of vital signs throughout the years. RESULTS: Overall, 17,905 casualties were recorded. Most casualties were young males (88.6%)-military personnel (52.7%), Syrian refugees (16.2%), Israeli civilians (11.5%), and Palestinians (9.0%). The median number of annual records from 2006 onward was significantly higher compared with before 2006 (1,000 [IQR, 792-1,470] vs. 142 [IQR, 129-156]). Between 2010 and 2018, documentation rate increased in all vital signs investigated including heart rate (56.3% vs. 1.0%), level of consciousness (55.1% vs. 0.3%), respiratory rate (51.8% vs. 0.3%), blood oxygen saturation (50.0% vs. 1.0%), Glasgow Coma Scale (48.2% vs. 0.4%), systolic blood pressure (45.7% vs. 0.8%), and pain (19.1% vs. 0.5%). CONCLUSION: Point of injury and prehospital documentation are rare yet essential for ongoing improvement of combat casualty care. The Israel Defense Forces Trauma Registry is one of the largest and oldest prehospital computerized military trauma registries in the world. This study shows a major improvement in the quantity and then in the quality of prehospital documentation throughout the years that affected guidelines and policy. Further work will focus on improving data completeness and accuracy. LEVEL OF EVIDENCE: Retrospective study, level III.

Prehospital definitive airway is not associated with improved survival in trauma patients.

BACKGROUND: The American College of Surgeons and the National Association of Emergency Medical Technicians advise securing a definitive airway if there is any doubt about the trauma patient's ability to maintain airway integrity. The objective of this study was to investigate the association between a success in securing a definitive airway in the prehospital setting and survival among trauma patients, in which the provider deemed a definitive airway was necessary. METHODS: The study included all trauma patients recorded in the Israel Defense Forces Trauma Registry between the years 2006 and 2018 for whom a prehospital attempt of securing a definitive airway was documented. The successful definitive airway group was defined by explicit documentation of success in either endotracheal intubation or cricothyrotomy. Logistic regression was performed to determine the association between success in securing a definitive airway and survival. RESULTS: A total of 566 (3.6%) trauma patients underwent attempts to secure a definitive airway (successful in 425 patients and unsuccessful in 141). Prehospital survival rates were similar (77.6% vs. 78.0%, p = 0.928) between the groups. Whether the definitive airway was successful did not affect the rates of prehospital survival, neither before (odds ratio, 0.98; 95% confidence interval, 0.61-1.54) nor after adjustment for the other factors (odds ratio, 0.91; 95% confidence interval, 0.55-1.46). CONCLUSION: This study was unable to find an association between a successful definitive airway in the prehospital setting and survival, even after adjustment for injury characteristics and in multiple models. Furthermore, survival rates were high among trauma patients in which the provider deemed a definitive airway as necessary yet failed in securing one. These results suggest that the liberal use of these invasive airway procedures in the prehospital setting should be reconsidered. LEVEL OF EVIDENCE: Retrospective study, lebel III.

Evaluation of sepsis using compensatory reserve measurement: A prospective clinical trial.

BACKGROUND: Sepsis, a leading cause of morbidity and mortality worldwide, characterized by metabolic and hemodynamic changes that can lead to multiorgan failure and death. The evaluation of a patient's condition is routinely performed by several objective criteria. 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. The present study's aim was to evaluate the applicability and the predictive value of the CRM during sepsis. METHODS: Data were prospectively collected from patients hospitalized in the department of surgery because of different inflammatory illnesses. All subjects were evaluated with hemodynamic, laboratory measurements and CRM throughout hospitalization. RESULTS: Of 100 subjects enrolled, 84 patients were not septic. The remaining 16 patients were in sepsis (Sequential Organ Failure Assessment [SOFA] score, >2), 6 of whom were in septic shock and 4 died. When nonseptic patients were compared with septic patients, statistical differences were found in C-reactive protein level (p < 0.0005), SOFA score (p < 0.0005), and CRM (p < 0.0001). Other parameters did not show any difference between groups. The area under the receiver operating characteristic curve for CRM was 1, significantly higher than the area under the receiver operating characteristic for heart rate (0.78), systolic blood pressure (0.67), quick SOFA (0.81), and respiratory rate (0.56). CONCLUSION: Clinical criteria, imaging, and laboratory features used to identify a septic patient are suboptimal. This demonstrates the need for a monitoring device capable of detecting rapidly, constantly, and simply the sum condition of the ill patient. We have shown that CRM was able to distinguish between severe septic and nonseptic patients early in the course of hospitalization and was significantly more sensitive than the conventional diagnostic tools. Such capability to assess the septic patients or even to triage these patients will surely aid treatment of sepsis. LEVEL OF EVIDENCE: Care management, level II.

Effect of tranexamic acid administration on acute traumatic coagulopathy in rats with polytrauma and hemorrhage.

Trauma and hemorrhagic shock can lead to acute traumatic coagulopathy (ATC) that is not fully reversed by prehospital resuscitation as simulated with a limited volume of fresh whole blood (FWB) in a rat model. Tranexamic Acid (TXA) is used as an anti-fibrinolytic agent to reduce surgical bleeding if administered prior to or during surgery, and to improve survival in trauma if given early after trauma. It is not clear from the existing clinical literature whether TXA has the same mechanism of action in both settings. This study sought to explore the molecular mechanisms of TXA activity in trauma and determine whether administration of TXA as a supplement to FWB resuscitation could attenuate the established ATC in a rat model simulating prehospital resuscitation of polytrauma and hemorrhagic shock. In a parallel in-vitro study, the effects on clotting assays of adding plasmin at varying doses along with either simultaneous addition of TXA or pre-incubation with TXA were measured, and the results suggested that maximum anti-fibrinolytic effect of TXA on plasmin-induced fibrinolysis required pre-incubation of TXA and plasmin prior to clot initiation. In the rat model, ATC was induced by polytrauma followed by 40% hemorrhage. One hour after trauma, the rats were resuscitated with FWB collected from donor rats. Vehicle or TXA (10mg/kg) was given as bolus either before trauma (TXA-BT), or 45min after trauma prior to resuscitation (TXA-AT). The TXA-BT group was included to contrast the coagulation effects of TXA when used as it is in elective surgery vs. what is actually feasible in real trauma patients (TXA-AT group). A single dose of TXA prior to trauma significantly delayed the onset of ATC from 30min to 120min after trauma as measured by a rise in prothrombin time (PT). The plasma d-dimer as well as plasminogen/fibrinogen ratio in traumatized liver of TXA-BT were significantly lower as compared to vehicle and TXA-AT. Wet/dry weight ratio and leukocytes infiltration of lungs were significantly decreased only if TXA was administrated later, prior to resuscitation (TXA-AT). In conclusion: Limited prehospital trauma resuscitation that includes FWB and TXA may not correct established systemic ATC, but rather may improve overall outcomes of resuscitation by attenuation of acute lung injury. By contrast, TXA given prior to trauma reduced levels of fibrinolysis at the site of tissue injury and circulatory d-dimer, and delayed development of coagulopathy independent of reduction of fibrinogen levels following trauma. These findings highlight the importance of early administration of TXA in trauma, and suggest that further optimization of dosing protocols in trauma to exploit TXA's various sites and modes of action may further improve patient outcomes.

Prehospital trauma experience of the Israel defense forces on the Syrian border 2013-2017.

BACKGROUND: The Israeli Defense Force Medical Corps (IDF-MC) is routinely collecting prehospital data to establish a prehospital registry. Since February 2013, Israel has been providing medical care to Syrian refugees. This unique humanitarian aid begins in prehospital settings and typically culminates in Israeli civilian hospitals. This report describes the accumulated experience of the IDF-MC to provide Syrian refugees with prehospital treatment. METHODS: Care provided by IDF-MC medical teams, including prehospital casualty care, is regularly documented and after-action reports are conducted. Records of casualties arriving at the Israeli-Syrian border from February 16, 2013, to December 31, 2017, were prospectively extracted from the IDF Trauma Registry. Patients who did not have a casualty card were excluded. The database included demographic information, injury signature and treatment given. RESULTS: During the study period, 2,785 Syrian casualties were treated, of whom 2,339 were trauma victims. The most common mechanism of injury was penetrating (60.4%). Prehospital lifesaving interventions included 127 endotracheal intubations, 30 cricothyroidotomies, 55 chest decompressions, and 58 tourniquets for extremity hemorrhage control. Remote Damage Control Resuscitation included reconstituted freeze-dried plasma (n = 75) and tranexamic acid (n = 222 casualties) with no adverse effects. CONCLUSION: The experience of the IDF-MC teams in caring for civilian casualties along a hostile international border is unique. In this capacity, the IDF-MC has demonstrated effectiveness in providing lifesaving and resuscitative interventions including tranexamic acid and freeze-dried plasma. In this experience, tourniquets have been effective in controlling hemorrhage when applied early and endotracheal intubation and cricothyroidotomy have provided effective airway options in select patients. Prehospital combat casualty care presents a significant challenge both in terms of providing adequate care and in terms of data collection and analysis. The experience described in this article is one example of effective, ongoing prehospital data gathering process. Efforts to provide medical relief to victims of the Syrian civil war continue to this day. While we hope for a better future, as long as these lessons continue to accumulate, it is our obligation to use them to support improvement of trauma care and hopefully save more lives. LEVEL OF EVIDENCE: Therapeutic, level III.

Damage Control Resuscitation.

Damage control resuscitation (DCR) is a strategy for resuscitating patients from hemorrhagic shock to rapidly restore homeostasis. Efforts are focused on blood product transfusion with whole blood or component therapy closely approximating whole blood, limited use of crystalloid to avoid dilutional coagulopathy, hypotensive resuscitation until bleeding control is achieved, empiric use of tranexamic acid, prevention of acidosis and hypothermia, and rapid definitive surgical control of bleeding. Patients receiving uncrossmatched Type O blood in the emergency department and later receiving cumulative transfusions of 10 or more red blood cell units in the initial 24-hour post-injury (massive transfusion) are widely recognized as being at increased risk of morbidity and mortality due to exsanguination. Ideally, these patients should be rapidly identified, however anticipating transfusion needs is challenging. Useful indicators of massive transfusion reviewed in this guideline include: systolic blood pressure <110 mmHg, heart rate > 105 bpm, hematocrit <32%, pH < 7.25, injury pattern (above-the-knee traumatic amputation especially if pelvic injury is present, multi-amputation, clinically obvious penetrating injury to chest or abdomen), >2 regions positive on Focused Assessment with Sonography for Trauma (FAST) scan, lactate concentration on admission >2.5, admission international normalized ratio ≥1.2-1.4, near infrared spectroscopy-derived StO2 < 75% (in practice, rarely available), BD > 6 meq/L. Unique aspects of out-of-hospital DCR (point of injury, en-route, and remote DCR) and in-hospital (Medical Treatment Facilities: Role 2b/Forward surgical teams - role 3/ combat support hospitals) are reviewed in this guideline, along with pediatric considerations.

Unexploded Ordnance Management.

The purpose of this Clinical Practice Guide is to provide details on the procedures to safely remove unexploded ordnance from combat patients, both loose and impaled, to minimize the risks to providers and the medical treatment facility while ensuring the best outcome for the patient. Military ordnance, to include bullets, grenades, flares, and explosive ordnance, retained by a patient can be a risk to all individuals and equipment along the continuum of care. This is especially true from the point of injury to the first treatment facility. Management of patients with unexploded ordnance either on or in their body is a rare event during combat surgery. Loose munitions are usually noted and easily removed prior to the patient receiving medical treatment. However, impaled munitions provide a significant challenge. These are usually caused by large caliber, high-velocity projectiles. Patients who survive to arrive at a treatment facility must be triaged safely and simultaneously treated appropriately to ensure both the survival of the patient and the treatment team. Between WWII and the Somalia conflict, there have been 36 reported cases of unexploded ordnance from U.S. soldiers. Since 2005, there have been six known cases during the U.S. wars in Afghanistan and Iraq and one additional case in Pakistan. Optimal outcomes require a basic knowledge of explosives and triggering mechanisms, as well as adherence to basic principles of trauma resuscitation and surgery.

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.

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.

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.