Airway Management With Noninvasive Positive Pressure Ventilation.

Noninvasive positive-pressure ventilation (NPPV) is a form of ventilatory support that does not require the placement of an advanced airway. The authors discuss the use of NPPV on patients who will likely benefit. The use of NPPV has reduced the need for patients to require intubation and/or mechanical ventilation in some cases, as well as benefits.

Team Rubicon Medical Response to Hurricane Dorian in the Bahamas.

On September 1, 2019, Hurricane Dorian made landfall as a category 5 hurricane on Great Abaco Island, Bahamas. Hurricane Dorian matched the "Labor Day" hurricane of 1935 as the strongest recorded Atlantic hurricane to make landfall with maximum sustained winds of 185 miles/h.1 At the request of the Government of the Bahamas, Team Rubicon activated a World Health Organization Type 1 Mobile Emergency Medical Team and responded to Great Abaco Island. The team provided medical care and reconnaissance of medical clinics on the island and surrounding cays….

Case Presentation: Creation and Utilization of a Novel Field Improvised Autologous Transfusion System in a Combat Casualty.

This case report describes the technical aspects in first use of a novel field improvised autologous transfusion (FIAT) system. It highlights a potential solution for specific trauma patients during advanced resuscitative care (ARC) and prolonged field care (PFC) scenarios where other blood products are not available.

Evaluation of an Online Educational Intervention to Increase Knowledge and Self-efficacy in Disaster Responders and Critical Care Transporters Caring for Individuals with Developmental Disabilities.

OBJECTIVE: Disability-related education is essential for disaster responders and critical care transporters to ensure positive patient outcomes. This pilot study evaluated the effect of an online educational intervention on disaster responders and critical care transporters' knowledge of and feelings of self-efficacy about caring for individuals with developmental disabilities. METHODS: A 1-group, pretest-posttest, quasi-experimental design was used. A convenience sample of 33 disaster responders and critical care transporters participated. RESULTS: Of the 33 participants, only 24% had received prior education on this topic, and 88% stated that such education would be beneficial to their care of patients. Nineteen participants completed both the pretest and posttest, and overall performance on knowledge items improved from 66% correct to 81% correct. Self-efficacy for caring for developmentally disabled individuals improved, with all 10 items showing a statistically significant improvement. CONCLUSION: Online education is recommended to improve the knowledge and self-efficacy of disaster responders and critical care transporters who care for this vulnerable population after disasters and emergencies. (Disaster Med Public Health Preparedness. 2019;13:677-681).

Intramuscular Tranexamic Acid in Tactical and Combat Settings.

BACKGROUND: Uncontrolled hemorrhage remains a leading cause of preventable death in tactical and combat settings. Alternate routes of delivery of tranexamic acid (TXA), an adjunct in the management of hemorrhagic shock, are being studied. A working group for the Committee for Tactical Emergency Casualty Care reviewed the available evidence on the potential role for intramuscular (IM) administration of TXA in nonhospital settings as soon as possible from the point of injury. METHODS: EMBASE and MEDLINE/PubMed databases were sequentially searched by medical librarians for evidence of TXA use in the following contexts and/or using the following keywords: prehospital, trauma, hemorrhagic shock, optimal timing, optimal dose, safe volume, incidence of venous thromboembolism (VTE), IM bioavailability. RESULTS: A total of 183 studies were reviewed. The strength of the available data was variable, generally weak in quality, and included laboratory research, case reports, retrospective observational reviews, and few prospective studies. Current volume and concentrations of available formulations of TXA make it, in theory, amenable to IM injection. Current bestpractice guidelines for large-volume injection (i.e., 5mL) support IM administration in four locations in the adult human body. One case series suggests complete bioavailability of IM TXA in healthy patients. Data are lacking on the efficacy and safety of IM TXA in hemorrhagic shock. CONCLUSION: There is currently insufficient evidence to support a strong recommendation for or against IM administration of TXA in the combat setting; however, there is an abundance of literature demonstrating efficacy and safety of TXA use in a broad range of patient populations. Balancing the available data and risk- benefit ratio, IM TXA should be considered a viable treatment option for tactical and combat applications. Additional studies should focus on the optimal dose and bioavailability of IM dosing of patients in hemorrhagic shock, with assessment of potential downstream sequelae.

A review of the landscape: Challenges and gaps in trauma response to civilian high threat mass casualty incidents.

The ultimate goal of the emergency response and trauma system is to reduce potentially preventable death from trauma. Tremendous advances in trauma care emerged from the past 15 years of United States' combat engagements around the globe. Unfortunately, combat and insurgency tactics have also metastasized to the civilian world, resulting in increasingly complex and dynamic acts of intentional mass violence. These high threat active violent incidents (AVIs) pose significant preparedness, response, and clinical care challenges to the civilian healthcare systems. Currently, there are several operational and policy gaps that limit the successful preparedness and response to AVIs and dynamic MCIs in the United States.

Case Report: Life Saving Application of Commercial Tourniquet in Pediatric Extremity Hemorrhage.

Hemorrhage is the leading preventable cause of death in civilian and military trauma. Recent data from the ongoing conflicts in Iraq and Afghanistan suggest that early and aggressive tourniquet utilization is a safe and effective way to dramatically reduce mortality from extremity hemorrhage. As a result, prehospital tourniquet use is now endorsed by a majority of professional emergency medicine, emergency medical service and trauma professional societies. However, there currently exists scant evidence supporting the efficacy of commercially available tourniquets in controlling extremity hemorrhage in pediatric trauma patients.

Translating Tactical Combat Casualty Care Lessons Learned to the High-Threat Civilian Setting: Tactical Emergency Casualty Care and the Hartford Consensus.

Combat operations necessitate bold thought and afford the opportunity to rapidly evolve and improve trauma care. The development and maturation of Tactical Combat Casualty Care (TCCC) is an important example of a critical process improvement strategy that reduced mortality in high-threat combat-related trauma. The Committee for Tactical Emergency Casualty Care (C-TECC) adapted the lessons of TCCC to the civilian high-threat environment and provided important all-hazards response principles for austere, dynamic, and resource-limited environments. The Hartford Consensus mobilized the resources of the American College of Surgeons to drive public policy regarding a more singular focus: hemorrhage control. The combined efforts of C-TECC and Hartford Consensus have helped redefine the practice of trauma care in high-threat scenarios across the United States.

Medical Provider Ballistic Protection at Active Shooter Events.

There is some controversy about whether ballistic protective equipment (body armor) is required for medical responders who may be called to respond to active shooter mass casualty incidents. In this article, we describe the ongoing evolution of recommendations to optimize medical care to injured victims at such an incident. We propose that body armor is not mandatory for medical responders participating in a rapid-response capacity, in keeping with the Hartford Consensus and Arlington Rescue Task Force models. However, we acknowledge that the development and implementation of these programs may benefit from the availability of such equipment as one component of risk mitigation. Many police agencies regularly retire body armor on a defined time schedule before the end of its effective service life. Coordination with law enforcement may allow such retired body armor to be available to other public safety agencies, such as fire and emergency medical services, providing some degree of ballistic protection to medical responders at little or no cost during the rare mass casualty incident. To provide visual demonstration of this concept, we tested three "retired" ballistic vests with ages ranging from 6 to 27 years. The vests were shot at close range using police-issue 9mm, .40 caliber, .45 caliber, and 12-gauge shotgun rounds. Photographs demonstrate that the vests maintained their ballistic protection and defeated all of these rounds.

Integration of Tactical Emergency Casualty Care Into the National Tactical Emergency Medical Support Competency Domains.

Tactical emergency medical support (TEMS) is a critical component of the out-of-hospital response to domestic high-threat incidents such as hostage scenarios, warrant service, active shooter or violent incidents, terrorist attacks, and other intentional mass casualty-producing acts. From its grass-roots inception in the form of medical support of select law enforcement special weapons and tactics (SWAT) units in the 1980s, the TEMS subspecialty of prehospital care has rapidly grown and evolved over the past 40 years. The National TEMS Initiative and Council (NTIC) competencies and training objectives are the only published recommendations of their kind and offer the opportunity for national standardization of TEMS training programs and a future accreditation process. Building on the previous work of the NTIC and the creation of acknowledged competency domains for TEMS and the acknowledged civilian translation of TCCC by the Committee for Tactical Emergency Casualty Care (C-TECC), the Joint Review Committee (JRC) has created an opportunity to bring forward the work in a form that could be operationally useful in an all-hazards and whole of community format.

The Ranger First Responder Program and Tactical Emergency Casualty Care Implementation: A Whole-Community Approach to Reducing Mortality From Active Violent Incidents.

Active violent incidents are dynamic and challenging situations that can produce a significant amount of preventable deaths. Lessons learned from the military?s experience in Afghanistan and Iraq through the Committee on Tactical Combat Casualty Care and the 75th Ranger Regiment?s Ranger First Responder Program have helped create the Committee for Tactical Emergency Casualty Care (C-TECC) to address the uniqueness of similar wounding patterns and to end preventable deaths. We propose a whole-community approach to active violent incidents, using the C-TECC Trauma Chain of Survival and a tiered approach for training and responsibilities: the first care provider, nonmedical professional first responders, medical first responders, and physicians and trauma surgeons. The different tiers are critical early links in the Chain of Survival and this approach will have a significant impact on active violent incidents.

Law enforcement-applied tourniquets: a case series of life-saving interventions.

Although the epidemiology of civilian trauma is distinct from that encountered in combat, in both settings, extremity hemorrhage remains a major preventable cause of potential mortality. The current paper describes the largest case series in the literature in which police officers arriving prior to emergency medical services applied commercially available field tourniquets to civilian victims of violent trauma. Although all 3 patients with vascular injury arrived at the receiving emergency department in extremis, they were successfully resuscitated and survived to discharge without major morbidity. While this outcome is likely multifactorial and highlights the exceptional care delivered by the modern trauma system, tourniquet application appears to have kept critically injured patients alive long enough to reach definitive trauma care. No patient had a tourniquet-related complication. This case series suggests that law enforcement officers can effectively identify indications for tourniquets and rapidly apply such life-saving interventions.