U.S. Military use of tourniquets from 2001 to 2010.

OBJECTIVE: This study was conducted to associate tourniquet use and survival in casualty care over a decade of war in order to provide evidence to emergency medical personnel for the implementation and efficacy of tourniquet use in a large trauma system. METHODS: This survey is a retrospective review of data extracted from a trauma registry. The decade (2001-2010) outcome trend analysis of tourniquet use in the current wars was made in order to associate tourniquet use and survival in an observational cohort design. RESULTS: Of 4,297 casualties with extremity trauma in the total study, 30% (1,272/4,297) had tourniquet use and 70% (3,025/4,297) did not. For all 4,297 casualties, the proportion of casualties with severe or critical extremity Abbreviated Injury Scales (AIS) increased during the years surveyed (p < 0.0001); the mean annual Injury Severity Score (ISS) rose from 13 to 21. Tourniquet use increased during the decade by almost tenfold from 4 to nearly 40% (p < 0.0001). Survival for casualties with isolated extremity injury varied by injury severity; the survival rate for AIS 3 (serious) was 98%, the rate for AIS 4 (severe) was 76%, and the rate for AIS 5 (critical) was 0%. Survival rates increased for casualties with injuries amenable to tourniquets but decreased for extremity injuries too proximal for tourniquets. CONCLUSIONS: Average injury severity increased during the decade of war for casualties with extremity injury. Both tourniquet use rates and casualty survival rates rose when injuries were amenable to tourniquets.

Emerging ideas: Interleukin-12 nanocoatings prevent open fracture-associated infections.

BACKGROUND: Infection is a major clinical complication of orthopaedic implants and prosthetic devices, and patients with traumatic open fractures have a high risk of infection that may exceed 30%. Surgical trauma, burns, and major injuries such as traumatic open fractures induce immunosuppression, decrease resistance to infection, and decrease production of T helper type 1 (Th1) cytokines. QUESTIONS/HYPOTHESES: Exogenous interleukin-12 p70 (IL-12p70 or IL-12), a natural cytokine that plays a central role in Th1 response and bridges innate and adaptive immunities, will reduce open fracture-associated infection. METHOD OF STUDY: We propose using exogenous IL-12 nanocoating to restore or enhance the body's natural defense system to combat pathogens. Rats will have a femur fractured, inoculated with Staphylococcus aureus or injected with phosphate buffered saline, left open for 1 hour, and then fixed with an intramedullary Kirschner wire with or without IL-12 nanocoating. Animals will be euthanized at postoperative Day 21; samples of blood, soft tissue, bone, and draining lymph nodes will be collected. Infection, bone healing, and local and systemic responses will be determined. SIGNIFICANCE: IL-12 nanocoating is a promising prophylactic means to modulate the host immune response to help prevent open fracture-associated infections and to avoid the problem of antibiotic resistance.

U.S. Military Experience From 2001 to 2010 With Extremity Fasciotomy in War Surgery.

INTRODUCTION: After trauma, compartment syndrome of the extremities is a common, disabling, and-if managed suboptimally-lethal problem. Its treatment by surgical fasciotomy continues to be useful but controversial. The purpose of this survey is to measure survival and fasciotomy in a large trauma system to characterize trends and to determine if fasciotomy is associated with improved survival. METHODS: We retrospectively surveyed data from a military trauma registry for U.S. casualties from 2001 to 2010. Casualties had extremity injury or extremity fasciotomy. We associated survival and fasciotomy. RESULTS: Of 17,166 casualties in the total study, 19% (3,313) had fasciotomy and 2.8% (481) had compartment syndrome. Annual fasciotomy rates started at 0% (2001) and rose to 26% (2010). For all casualties, the survival rate initially was high (100%) but decreased steadily until its nadir (96.4%) in 2005. Thereafter, it increased to make a V-shaped trend with reversal occurring after fielding two interventions within the trauma system specifically for casualties at risk for fasciotomy-tourniquet use and a fasciotomy education program. CONCLUSIONS: Over a decade of war, the survival rate of extremity injured casualties was associated with two trauma system interventions-tourniquet usage and a fasciotomy education program. The current example of measuring implementation of initiatives may be useful as a model for future attempted improvements in health care.

Evaluation of Contingency Telemedical Support to Improve Casualty Care at a Simulated Military Intermediate Resuscitation Facility: The EM-ANGEL Study.

OBJECTIVE: We sought to determine whether Contingency Telemedical Support (CTS) improves the success rate and efficiency of primary care providers performing critical actions during simulated combat trauma resuscitation. Critical actions included advanced airway, chest decompression, extremity hemorrhage control, hypothermia prevention, antibiotics and analgesics, and hypotensive resuscitation, among others. BACKGROUND: Recent studies report improved survival associated with skilled triage and treatment in the out-of-hospital/preoperative phase of combat casualty care. Historically, ground combat units are assigned primary care physicians and physician assistants as medical staff, due to resource limitations. Although they are recognized as optimal resuscitators, demand for military trauma surgeons and emergency physicians exceeds supply and is unlikely to improve in the near term. METHODS: A prospective trial of telemedical mentoring during a casualty resuscitation encounter was studied using a high-fidelity patient simulator (HFPS). Subjects were randomized and formed into experimental (CTS) or control teams. CTS team leaders were equipped with a headset/microphone interface and telementored by a combat-experienced emergency physician or trauma surgeon. A standardized, scripted clinical scenario and HFPS were used with 14 critical actions. At completion, subjects were surveyed. Statistical approach included contingency table analysis, two-tailed t-test, and correlation coefficient. This study was reviewed and approved by our institutional review board (IRB). RESULTS: Eighteen CTS teams and 16 control teams were studied. By intention-to-treat ITT analysis, 89% of CTS teams versus 56% of controls completed all life-threatening inventions (LSIs) (p<.01); 78% versus 19% completed all critical actions (p<.01); and 89% versus 56% established advanced airways within 8 minutes (p<.06). Average time to completion in minutes (95% confidence interval [CI] 95) was 12 minutes (10?14) for CTS versus 18 (16?20) for controls, with 75% of control teams not completing all critical actions. CONCLUSION: In this model, real-time telementoring of simulated trauma resuscitation was feasible and improved accuracy and efficiency of non?emergency-trained resuscitators. Clinical validation and replicated study of these findings for guiding remote damage control resuscitation are warranted.

U.s. Military experience with junctional wounds in war from 2001 to 2010.

BACKGROUND: In 2012, we reported on junctional wounds in war, but only of the few injuries that were critically severe. OBJECTIVE: The purpose of the present study is to associate a wide range of junctional wounds and casualty survival over a decade in order to evidence opportunities for improvement in trauma care within a large healthcare system. METHODS: We retrospectively surveyed data from a military trauma registry. We associated survival and injuries at the junction of the trunk and appendages in the current war (2001 to 2010). RESULTS: The junctional injury rate rose 14-fold from 0%, its minimum in 2001, to 5%, its maximum in 2010. Of the 833 casualties with junctional injury in the study, the survival rate was 83%; its change was not statistically significant over time. Most casualties had severe extremity injuries and associated injuries of other body regions such as the face and head. CONCLUSIONS: Junctional injury is common, severe, disabling, and lethal. The findings of this study may increase awareness of junctional injury. Opportunities for improvement which we identified included further research on the future addition of junctional codes (such as neck diagnoses) in order to align research methods to clinical care.