Teamwork matters: The association between nontechnical skills and cardiac arrest in trauma patients presenting with hypotension.

BACKGROUND: The impact of trauma team dynamics on outcomes in injured patients is not completely understood. We sought to evaluate the association between trauma team function, as measured by a modified Trauma Non-Technical Skills assessment, and cardiac arrest in hypotensive trauma patients. We hypothesized that better team function is associated with a decreased probability of developing cardiac arrest. METHODS: Trauma video review was used to collect data from resuscitations of adult hypotensive trauma patients at 19 centers. Hypotension at emergency department presentation was defined as an initial systolic blood pressure <90 mm Hg or an initial systolic blood pressure ≥90 mm Hg followed by a systolic blood pressure <90 mm Hg within the first 5 minutes. Team dynamics were scored using a modified Trauma Non-Technical Skills assessment composed of 5 domains with combined scores ranging from 5 (best) to 15 (worst). Scores were compared between cardiac arrest/noncardiac arrest cases in the trauma bay. Logistic regression was used to evaluate the independent association between the Trauma Non-Technical Skills assessment and cardiac arrest. RESULTS: A total of 430 patients were included (median age 43 years [interquartile range: 29-61]; 71.8% male; 36% penetrating mechanism; median Injury Severity Score 20 [10-33]; 11% experienced cardiac arrest in trauma bay). The median total Trauma Non-Technical Skills assessment score was 7 (6-9), higher in patients who experienced cardiac arrest in the trauma bay (9 [6-10] vs 7 [6-9]; P = .016). This association persisted after controlling for age, sex, mechanism, injury severity, initial systolic blood pressure, and initial Glasgow Coma Scale score (adjusted odds ratio: 1.28; 95% confidence interval:1.11-1.48; P < .001), indicating a ∼3% higher predicted probability of cardiac arrest per Trauma Non-Technical Skills point. CONCLUSION: Better team function is independently associated with a decreased probability of cardiac arrest in trauma patients presenting with hypotension. This suggests that trauma team training may improve outcomes in peri-arrest patients.

Implementing the IMIST-AMBO tool for paramedic to trauma team handovers: a video review analysis.

OBJECTIVE: Patient handover between paramedics and the trauma team is vulnerable to communication errors that may adversely affect patient care. This study assesses the feasibility of a handover tool, IMIST-AMBO (acronym of categories), implementation in the trauma bay and evaluates the degree to which it improves handover metrics. METHODS: This is a prospective observational cohort study conducted at Canada's largest level-one trauma center. Feasibility of the tool implementation and improvement in handover metrics were assessed. Strategies for implementation included distribution of an educational video and posters, and point-of-care reminders in the trauma bay. Two reviewers independently assessed video recordings of handovers to evaluate handover metrics. Findings were compared to data obtained during a knowledge gap analysis conducted prior to the initiation of this study at the same institution. RESULTS: Over 13 weeks (August to November 2020), 140 videos were recorded, of which 80 used the IMIST-AMBO tool (compliance of 57%). Paramedic adherence to the handover structure occurred in 70.4% of cases, with greater adherence to the IMIST (82.2%) compared to the AMBO (47.1%) section. The mean (± standard deviation) handover duration was shorter (1 min:58 s ± 0:44 s during implementation vs. 2 min:47 s ± 1:14 s pre-implementation, [p < 0.001]). Frequency of parallel conversations and informal handovers improved (61% to 30% and 65% to 13%, [p < 0.001], respectively). Interruptions during the handover decreased from 3.05 (± 1.95) to 1.5 (± 1.7), p < 0.001. The tool was received favorably among study participants. CONCLUSION: The IMIST-AMBO tool reduced the frequency of interruptions, parallel conversations, and informal handovers during paramedic-trauma team handovers at our institution. The quality and amount of information communicated per handover improved, all with a decrease in handover duration. The IMIST-AMBO tool may be applied to other trauma centers across Canada, or more broadly on an international scale.

RéSUMé: OBJECTIFS: Le transfert des patients entre les ambulanciers paramédicaux et l'équipe de traumatologie est vulnérable aux erreurs de communication qui peuvent nuire aux soins aux patients. Cette étude évalue la faisabilité d'un outil de transfert, IMIST-AMBO (acronyme des catégories), mis en œuvre dans le service de traumatologie et évalue dans quelle mesure il améliore les paramètres de transfert. MéTHODES: Il s'agit d'une étude de cohorte observationnelle prospective menée dans le plus grand centre de traumatologie de niveau 1 du Canada. La faisabilité de la mise en œuvre de l'outil et l'amélioration des paramètres de transfert ont été évaluées. Les stratégies de mise en œuvre comprenaient la distribution d'une vidéo et d'affiches éducatives, ainsi que des rappels au point de service dans la salle de traumatologie. Deux examinateurs ont évalué indépendamment les enregistrements vidéo des transferts pour évaluer les paramètres de transfert. Les résultats ont été comparés aux données obtenues lors d'une analyse des lacunes en matière de connaissances réalisée avant le lancement de cette étude dans le même établissement. RéSULTATS: Sur 13 semaines (août à novembre 2020), 140 vidéos ont été enregistrées, dont 80 ont utilisé l'outil IMIST-AMBO (conformité de 57%). L'adhésion des ambulanciers paramédicaux à la structure de transfert s'est produite dans 70.4% des cas, avec une plus grande adhésion à l'IMIST (82.2%) que l'AMBO (47,1%). La durée moyenne (± écart-type) du transfert était plus courte (1 min: 58 s ± 0: 44 s pendant la mise en œuvre contre 2 min: 47 s ± 1: 14 s avant la mise en œuvre, p < 0.001). La fréquence des conversations parallèles et des transferts informels s'est améliorée (de 61% à 30% et de 65% à 13%, [p < 0.001], respectivement). Les interruptions pendant le transfert ont diminué de 3.05 (± 1.95) à 1.5 (± 1.7), p < 0.001. L'outil a été accueilli favorablement par les participants à l'étude. CONCLUSION: L'outil IMIST-AMBO a réduit la fréquence des interruptions, des conversations parallèles et des transferts informels pendant les transferts de l'équipe paramédicale de traumatologie dans notre établissement. La qualité et la quantité d'informations communiquées par transfert se sont améliorées, tout en réduisant la durée du transfert. L'outil IMIST-AMBO peut être appliqué à d'autres centres de traumatologie à travers le Canada, ou plus largement à l'échelle internationale.

Moving the needle on time to resuscitation: An EAST prospective multicenter study of vascular access in hypotensive injured patients using trauma video review.

BACKGROUND: Vascular access in hypotensive trauma patients is challenging. Little evidence exists on the time required and success rates of vascular access types. We hypothesized that intraosseous (IO) access would be faster and more successful than peripheral intravenous (PIV) and central venous catheter (CVC) access in hypotensive patients. METHODS: An EAST prospective multicenter trial was performed; 19 centers provided data. Trauma video review was used to evaluate the resuscitations of hypotensive (systolic blood pressure ≤90 mm Hg) trauma patients. Highly granular data from video recordings were abstracted. Data collected included vascular access attempt type, location, success rate, and procedural time. Demographic and injury-specific variables were obtained from the medical record. Success rates, procedural durations, and time to resuscitation were compared among access strategies (IO vs. PIV vs. CVC). RESULTS: There were 1,410 access attempts that occurred in 581 patients with a median age of 40 years (27-59 years) and an Injury Severity Score of 22 [10-34]. Nine hundred thirty-two PIV, 204 IO, and 249 CVC were attempted. Seventy percent of access attempts were successful but were significantly less likely to be successful in females (64% vs. 71%, p = 0.01). Median time to any access was 5.0 minutes (3.2-8.0 minutes). Intraosseous had higher success rates than PIV or CVC (93% vs. 67% vs. 59%, p < 0.001) and remained higher after subsequent failures (second attempt, 85% vs. 59% vs. 69%, p = 0.08; third attempt, 100% vs. 33% vs. 67%, p = 0.002). Duration varied by access type (IO, 36 [23-60] seconds; PIV, 44 [31-61] seconds; CVC 171 [105-298]seconds) and was significantly different between IO versus CVC ( p < 0.001) and PIV versus CVC ( p < 0.001) but not PIV versus IO. Time to resuscitation initiation was shorter in patients whose initial access attempt was IO, 5.8 minutes versus 6.7 minutes ( p = 0.015). This was more pronounced in patients arriving to the hospital with no established access (5.7 minutes vs. 7.5 minutes, p = 0.001). CONCLUSION: Intraosseous is as fast as PIV and more likely to be successful compared with other access strategies in hypotensive trauma patients. Patients whose initial access attempt was IO were resuscitated more expeditiously. Intraosseous access should be considered a first line therapy in hypotensive trauma patients. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level II.

Rationale and Methods for Updated Guidelines for the Management of Penetrating Traumatic Brain Injury.

Penetrating traumatic brain injury (pTBI) affects civilian and military populations resulting in significant morbidity, mortality, and healthcare costs. No up-to-date and evidence-based guidelines exist to assist modern medical and surgical management of these complex injuries. A preliminary literature search revealed a need for updated guidelines, supported by the Brain Trauma Foundation. Methodologists experienced in TBI guidelines were recruited to support project development alongside two cochairs and a diverse steering committee. An expert multi-disciplinary workgroup was established and vetted to inform key clinical questions, to perform an evidence review and the development of recommendations relevant to pTBI. The methodological approach for the project was finalized. The development of up-to-date evidence- and consensus-based clinical care guidelines and algorithms for pTBI will provide critical guidance to care providers in the pre-hospital and emergent, medical, and surgical settings.

Management of Severe Crush Injuries in Austere Environments: A Special Operations Perspective.

Crush injuries present a challenging case for medical providers and require knowledge and skill to manage the subsequent damage to multiple organ systems. In an austere environment, in which resources are limited and evacuation time is extensive, a medic must be prepared to identify trends and predict outcomes based on the mechanism of injury and patient presentation. These injuries occur in a variety of environments from motor vehicle accidents (at home or abroad) to natural disasters and building collapses. Crush injury can lead to compartment syndrome, traumatic rhabdomyolysis, arrythmias, and metabolic acidosis, especially for patients with extended treatment and extrication times. While crush syndrome occurs due to the systemic effects of the injury, the onset can be as early as 1 hour postinjury. With a comprehensive understanding of the pathophysiology, diagnosis, management, and tactical considerations, a prehospital provider can optimize patient outcomes and be prepared with the tools they have on hand for the progression of crush injury into crush syndrome.

Closed loop communication in the trauma bay: identifying opportunities for team performance improvement through a video review analysis.

OBJECTIVES: Communication among trauma team members in the trauma bay is vulnerable to errors, which may impact patient outcomes. We used the previously validated trauma-non-technical skills (T-NOTECHS) tool to identify communication gaps during patient management in the trauma bay and to inform development strategies to improve team performance. METHODS: Two reviewers independently assessed non-technical skills of team members through video footage at Sunnybrook Health Sciences Centre. Team performance was measured using T-NOTECHS across five domains using a five-point Likert scale (lower score indicating worse performance): (1) leadership; (2) cooperation and resource management; (3) communication and interaction; (4) assessment and decision making; (5) situation awareness/coping with stress. Secondary outcomes assessed the number of callouts, closed loop communications and parallel conversations. RESULTS: The study included 55 trauma activations. Injury severity score (ISS) was used as a measure of trauma severity. A case with an ISS score ≥ 16 was considered severe. ISS was ≥ 16 in 37% of cases. Communication and interaction scored significantly lower compared to all other domains (p < 0.0001). There were significantly more callouts and completed closed loop communications in more severe cases compared to less severe cases (p = 0.017 for both). Incomplete closed loop communications and parallel conversations were identified, irrespective of case severity. CONCLUSION: A lower communication score was identified using T-NOTECHS, attributed to incomplete closed loop communications and parallel conversations. Through video review of trauma team activations, opportunities for improvement in communication can be identified by the T-NOTECHS tool, as well as specifically identifying callouts and closed loop communication. This process may be useful for trauma programs as part of a quality improvement program on communication skills and team performance.

RéSUMé: OBJECTIFS : La communication entre les membres de l'équipe de traumatologie dans la salle de traumatologie est vulnérable aux erreurs, ce qui peut avoir un impact sur les résultats des patients. Nous avons utilisé l'outil de compétences non techniques en traumatologie (T-NOTECHS) précédemment validé pour identifier les lacunes en matière de communication pendant la prise en charge des patients dans la salle de traumatologie et pour informer les stratégies de développement visant à améliorer les performances de l'équipe. MéTHODES: Deux examinateurs ont évalué de manière indépendante les compétences non techniques des membres de l'équipe au moyen de séquences vidéo réalisées au Sunnybrook Health Sciences Centre. La performance de l'équipe a été mesurée à l'aide de la T-NOTECHS dans cinq domaines à l'aide d'une échelle de Likert à cinq points (un score plus bas indiquant une performance plus faible) : (1) leadership ; (2) coopération et gestion des ressources ; (3) communication et interaction ; (4) évaluation et prise de décision ; (5) conscience de la situation/ gestion du stress. Les résultats secondaires ont évalué le nombre d'appels, de communications en boucle fermée et de conversations parallèles. RéSULTATS: L'étude a porté sur 55 activations de traumatismes. Le score de gravité des blessures (ISS) a été utilisé comme mesure de la gravité du traumatisme. Un cas présentant un score ISS ≥ 16 était considéré comme grave. L'ISS était ≥ 16 dans 37 % des cas. La communication et l'interaction ont obtenu des scores significativement plus faibles par rapport à tous les autres domaines (p<0,0001). Il y avait significativement plus d'appels et de communications en boucle fermée terminées dans les cas plus graves que dans les cas moins graves (p = 0.017 pour les deux). Des communications incomplètes en boucle fermée et des conversations parallèles ont été identifiées, indépendamment de la gravité du cas. CONCLUSION: Un score de communication plus faible a été identifié en utilisant le T-NOTECHS, attribué à des communications incomplètes en boucle fermée et à des conversations parallèles. Grâce à l'examen vidéo des activations de l'équipe de traumatologie, les possibilités d'amélioration de la communication peuvent être identifiées par l'outil T-NOTECHS, ainsi que l'identification spécifique des appels et de la communication en boucle fermée. Ce processus peut être utile pour les programmes de traumatologie dans le cadre d'un programme d'amélioration de la qualité sur les compétences de communication et la performance de l'équipe.

Freeze-dried plasma for major trauma - Systematic review and meta-analysis.

BACKGROUND: Treatment of acute trauma coagulopathy has shifted toward rapid replacement of coagulation factors with frozen plasma (FP). There are logistic difficulties in providing FP. Freeze-dried plasma (FDP) may have logistical advantages including easier storage and rapid preparation time. This review assesses the feasibility, efficacy, and safety of FDP in trauma. STUDY DESIGN AND METHODS: Studies were searched from Medline, Embase, Cochrane Controlled Trials Register, ClinicalTrials.gov, and Google Scholar. Observational and randomized controlled trials (RCTs) assessing FDP use in trauma were included. Trauma animal models addressing FDP use were also included. Bias was assessed using validated tools. Primary outcome was efficacy, and secondary outcomes were feasibility and safety. Meta-analyses were conducted using random-effect models. Evidence was graded using Grading of Recommendations Assessment, Development, and Evaluation profile. RESULTS: Twelve human studies (RCT, 1; observational, 11) and 15 animal studies were included. Overall, studies demonstrated moderate risk of bias. Data from two studies (n = 119) were combined for meta-analyses for mortality and transfusion of allogeneic blood products (ABPs). For both outcomes, no difference was identified. For mortality, pooled odds ratio was 0.66 (95% confidence interval, 0.29-1.49), with I2 = 0%. Use of FDP is feasible, and no adverse events were reported. Animal data suggest similar results for coagulation and anti-inflammatory profiles for FP and FDP. CONCLUSION: Human data assessing FDP use in trauma report no difference in mortality and transfusion of ABPs in patients receiving FDP compared with FP. Data from animal trauma studies report no difference in coagulation factor and anti-inflammatory profiles between FP and FDP. Results should be interpreted with caution because most studies were observational and have heterogeneous population (military and civilian trauma) and a moderate risk of bias. Well-designed prospective observational studies or, preferentially, RCTs are warranted to answer FDP's effect on laboratory (coagulation factor levels), transfusion (number of ABPs), and clinical outcomes (organ dysfunction, length of stay, and mortality). LEVEL OF EVIDENCE: Systematic review and meta-analysis, level IV.

Extracorporeal membrane oxygenation use in Trauma Quality Improvement Program centers: Temporal trends and future directions.

BACKGROUND: Increased clinical experience and the decreased need for systemic anticoagulation have renewed interest in the use of extracorporeal membrane oxygenation (ECMO) for posttraumatic respiratory and cardiopulmonary failure. The objectives of this study were to describe the incidence and temporal trends of ECMO use at trauma centers, the outcomes of trauma patients undergoing ECMO, and the characteristics of trauma centers providing ECMO. METHODS: Data were derived from the American College of Surgeons Trauma Quality Improvement Program data set. We included adults with at least one severe injury admitted to a level I or II trauma center between 2012 and 2016 who received at least 1 day of mechanical ventilation. Patients were categorized based on whether or not they received ECMO during their admission. The primary outcome was change in the incidence of ECMO across study years. We also evaluated patient outcomes and variation in ECMO volumes across centers. RESULTS: Of 194,314 severely injured patients undergoing mechanical ventilation across 450 centers, 269 (0.14%) received ECMO. Extracorporeal membrane oxygenation patients had significantly higher mortality than non-ECMO patients (32% vs. 19%). The standardized rate of ECMO from 2012 to 2016 increased significantly from 75.2 to 179.0 cases per 100,000 severely injured patients undergoing mechanical ventilation. The average annual growth rate was 24%. Of the 82 centers(18%) reporting at least 1 ECMO trauma case, 34 (41%) reported only a single case. CONCLUSION: The use of ECMO for trauma, although rare, is rapidly increasing. Two thirds of patients who receive ECMO following traumatic injury survive their hospitalization. These data suggest that ECMO represents a potential treatment strategy for trauma patients with respiratory or cardiopulmonary failure. However, given the rarity of the procedure, there exists an opportunity to develop practice guidelines regarding the indications for, and approach to, ECMO in the setting of trauma. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.

The Value of Live Tissue Training for Combat Casualty Care: A Survey of Canadian Combat Medics With Battlefield Experience in Afghanistan.

INTRODUCTION: The optimum method for training military personnel for combat casualty care is unknown. In particular, there is debate regarding the incremental benefit of live animal tissue training (LTT) over inanimate human patient simulators (HPSs). Although both LTT and HPS are currently used for predeployment training, the efficacy of these models has not been established. MATERIALS AND METHODS: Canadian Armed Forces combat medics, deployed to Afghanistan between 2006 and 2011, were surveyed retrospectively regarding their experience with combat casualty care and predeployment training. HPSs were used to prepare these combat medics for early rotations. In later years, personnel received a combination of training modalities including HPS and LTT, using anaesthetized porcine models in accordance with appropriate animal care standards. Among those deployed on multiple rotations, there was a cohort who was prepared for deployment using only HPS training, and who later were prepared using mixed-modality training, which included LTT. We asked these medics to compare their predeployment training using HPS only versus their mixed-modality training in how each training package prepared them for battlefield trauma care. RESULTS: Thirty-eight individuals responded, with 20 respondents deployed on multiple rotations. Respondents performed life-saving skills during 89% of the rotations. Self-perceived competence and preparedness were notably higher after incorporation of LTT than after HPS alone. Of 17 respondents deployed on both early and late rotations, the majority felt the latter training was more worthwhile. In addition, almost all individuals felt that LTT should be added to HPS training. Narrative comments described multiple benefits of adding LTT to other types of training. CONCLUSIONS: Among many experienced Canadian Armed Forces personnel, LTT is considered essential predeployment preparation. Individuals who experienced only HPS training before active duty on their first combat deployment reported feeling more competent on subsequent combat deployments after the addition of live tissue models. IMPACT: There has been a movement away from the use of LTT in preparing combat medics for deployment. This article suggests that we should reconsider any decision to completely exclude Live Tissue Training as part of our training plan for combat medics. RECOMMENDATIONS: Military medical organizations should consider judiciously incorporating LTT with human patient simulation training to prepare combat medics for treating battlefield trauma.

The University of Toronto's lasting contribution to war surgery: how Maj. L. Bruce Robertson fundamentally transformed thinking toward blood transfusion during the First World War.

SUMMARY: During the Great War, Canadian military surgeons produced some of the greatest innovations to improve survival on the battlefield. Arguably, the most important was bringing blood transfusion practice close to the edge of the battlefield to resuscitate the many casualties dying of hemorrhagic shock. Dr. L. Bruce Robertson of the Canadian Army Medical Corps was the pioneering surgeon from the University of Toronto who was able to demonstrate the benefit of blood transfusions near the front line and counter the belief that saline was the resuscitation fluid of choice in military medicine. Robertson would go on to survive the Great War, but would be taken early in life by influenza. Despite his life and career being cut short, Robertson's work is still carried on today by many military medical organizations who strive to bring blood to the wounded in austere and dangerous settings. This article has an Appendix, available at canjsurg.ca.

A comparison of live tissue training and high-fidelity patient simulator: A pilot study in battlefield trauma training.

BACKGROUND: Trauma procedural and management skills are often learned on live tissue. However, there is increasing pressure to use simulators because their fidelity improves and as ethical concerns increase. We randomized military medical technicians (medics) to training on either simulators or live tissue to learn combat casualty care skills to determine if the choice of modality was associated with differences in skill uptake. METHODS: Twenty medics were randomized to trauma training using either simulators or live tissue. Medics were trained to perform five combat casualty care tasks (surgical airway, needle decompression, tourniquet application, wound packing, and intraosseous line insertion). We measured skill uptake using a structured assessment tool. The medics also completed exit questionnaires and interviews to determine which modality they preferred. RESULTS: We found no difference between groups trained with live tissue versus simulators in how they completed each combat casualty care skill. However, we did find that the modality of assessment affected the assessment score. Finally, we found that medics preferred trauma training on live tissue because of the fidelity of tissue handling in live tissue models. However, they also felt that training on simulators also provided additional training value. CONCLUSION: We found no difference in performance between medics trained on simulators versus live tissue models. Even so, medics preferred live tissue training over simulation. However, more studies are required, and future studies need to address the measurement bias of measuring outcomes in the same model on which the study participants are trained. LEVEL OF EVIDENCE: Therapeutic/care management study, level II.

Factors affecting mortality of pediatric trauma patients encountered in Kandahar, Afghanistan.

BACKGROUND: The North Atlantic Treaty Organization (NATO) Role 3 Multinational Medical Unit (R3-MMU) is a tertiary care trauma facility that receives casualties, both coalition and civilian, and provides humanitarian medical assistance when able to the Kandahar province in southern Afghanistan. We examined the cohort of pediatric patients evaluated at the facility during a 16-month period to determine the characteristics and care requirements of this unique patient population. METHODS: A database of Afghan patients younger than 18 years of age admitted to the NATO R3-MMU between January 2010 and April 2011 was developed from the Joint Theatre Trauma Registry. This patient cohort was analyzed to determine demographics, injury mechanism, injury severity, resource utilization and factors associated with mortality. RESULTS: A total of 263 children were admitted to the NATO R3-MMU during the study period, representing 12% of all trauma admissions during this time period. The median age was 9 years (range 3 mo-17 yr) with a predominance of male patients (82%). Battle-related trauma was responsible for 62% of admissions, with explosive blast injury constituting the predominant mechanism (42%). The average injury severity score was 12.3 ± 9.3. Overall mortality was 8%. Factors associated with increased risk of death included admission acidosis, coagulopathy, hypothermia and female sex. CONCLUSION: Children represent a significant proportion of traumatic injuries encountered in a modern war zone; many of them are critically injured. Organizations that provide health care in such environments should be prepared to care for this patient population where their mandates and facilities allow for it.

CONTEXTE: L'Unité médicale multinationale de Rôle 3 (UMM R3) de l'Organisation du Traité de l'Atlantique Nord est un établissement de soins traumatologiques tertiaires qui reçoit les blessés des troupes de la coalition et de la population civile et offre une aide médicale humanitaire lorsqu'elle le peut à la population de la province de Kandahar, dans le Sud de l'Afghanistan. Nous avons étudié la cohorte de patients pédiatriques évalués à cet établissement durant une période de 16 mois afin de déterminer les caractéristiques et les besoins médicaux de cette population unique de patients. MÉTHODES: Une base de données sur les patients afghans de moins de 18 ans admis à l'UMM R3 entre janvier 2010 et avril 2011 a été établie à partir d'un registre des traumatismes liés au théâtre des opérations conjointes (Joint Theatre Trauma Registry). Cette cohorte de patients a été analysée de manière à dégager les caractéristiques démographiques, le mécanisme des traumatismes, la gravité des blessures, l'utilisation des ressources et les facteurs associés à la mortalité. RÉSULTANTS: En tout, 263 enfants ont été admis à l'UMM R3 pendant la période de l'étude, ce qui représente 12 % de toutes les admissions en traumatologie pendant cette période. L'âge médian était de 9 ans (entre 3 mois et 17 ans) et les patients étaient majoritairement de sexe masculin (82 %). Les traumatismes liés aux combats ont représenté 62 % des admissions, les blessures consécutives à une explosion en étant le mécanisme principal (42 %). Le score moyen de gravité des blessures était de 12,3 ± 9,3. La mortalité globale a été de 8 %. Les facteurs associés à un risque accru de décès incluaient l'acidose au moment de l'admission, la coagulopathie, l'hypothermie et le fait d'être de sexe féminin. CONCLUSION: Les enfants représentent une proportion significative des traumatismes rencontrés en zone de guerre, et beaucoup d'entre eux sont grièvement blessés. Les organismes qui fournissent des soins de santé dans de tels environnements devraient être prêts à soigner cette population de patients là où leur mandat et leurs installations le permettent.

The Canadian Armed Forces medical response to Typhoon Haiyan.

BACKGROUND: In the setting of international disaster response, an important challenge is determining when it is appropriate to withdraw deployed assets as the acute disaster response transitions to recovery and rebuilding. We describe our experience with realtime data collection during our medical response to Typhoon Haiyan as a means to guide military aid mission parameters. METHODS: The operational medical headquarters prospectively developed a database for use in this mission. Mobile medical teams (MMTs) were deployed to provide primary care, and the nurse designated to each MMT was responsible for entering and transmitting data daily to the medical headquarters. Data collected included the MMT location, basic patient demographics, the primary reason for the encounter and any treatment provided. These encounters were then classified as disaster, acute or chronic. RESULTS: Between Nov. 16 and Dec. 16, 2013, medical care was provided to 6596 local nationals; 238 (3.6%) had disaster-related illness or injury, 4321 (65.5%) had acute postdisaster medical conditions and 2037 (30.9%) sought medical care for chronic conditions. Of the 257 patients with traumatic injuries, 28 (11%) had disaster-related injuries and 214 (83%) had acute injuries that occurred postdisaster. CONCLUSION: The data collected during the mission to the Phillippines was compiled with performance metrics from the other Disaster Assistance Response Team components to help advise the Canadian government regarding mission duration. We recommended that data collection continue on all future missions and be modified to provide further information to larger disaster coordination teams, such as the United Nations Office for the Coordination of Humanitarian Affairs.

CONTEXTE: Dans le domaine de l'intervention internationale en cas de catastrophe, il est souvent difficile de déterminer le moment approprié pour retirer les ressources déployées alors que l'on passe de la première intervention d'urgence à la période de rétablissement et de reconstruction. Nous décrirons ici notre expérience de collecte de données en temps réel durant notre intervention médicale après le typhon Haiyan, dans le but d'orienter les paramètres de mission de l'aide militaire. MÉTHODES: Le quartier général des opérations médicales avait préparé d'avance la base de données qui a été utilisée lors de cette mission. Des équipes médicales mobiles ont été déployées pour fournir des soins de base, et une infirmière ou un infirmier désigné dans chaque équipe était chargé d'entrer et de transmettre les données quotidiennement au quartier général des opérations médicales. Les données recueillies comprenaient la position de l'équipe médicale mobile, des données démographiques de base sur les patients, la raison première de la rencontre et les traitements fournis. Ces rencontres étaient ensuite classées comme catastrophiques, aiguës ou chroniques. RÉSULTANTS: Du 16 novembre au 16 décembre 2013, des soins médicaux ont été prodigués à 6596 Philippins; 238 personnes (3,6 %) avaient des maladies ou des blessures liées au typhon, 4321 personnes (65,5 %) avaient des problèmes médicaux aigus d'après catastrophe et 2037 personnes (30,9 %) avaient besoin de soins pour des affections chroniques. Des 257 patients ayant subi des lésions traumatiques, 28 (11 %) avaient des blessures liées à la catastrophe et 214 (83 %) avaient des blessures aiguës reçues après la catastrophe. CONCLUSION: Les données recueillies durant la mission aux Philippines ont été compilées avec les indicateurs de rendement des autres composantes de l'équipe d'intervention en cas de catastrophe pour conseiller le gouvernement canadien au sujet de la durée des missions. Nous recommandons que la collecte de données se poursuive durant toutes les missions futures et soit modifiée afin de fournir plus de renseignements aux plus grandes équipes de coordination des interventions en cas de catastrophe, comme le Bureau de la coordination des affaires humanitaires de l'Organisation des Nations Unies.

Acute nontraumatic general surgical conditions on a combat deployment.

BACKGROUND: Literature is lacking on acute surgical problems that may be encountered on military deployment; even less has been written on whether or not any of these surgical problems could have been avoided with more focused predeployment screening. We sought to determine the burden of illness attributable to acute nontraumatic general surgical problems while on deployment and to identify areas where more rigorous predeployment screening could be implemented to decrease surgical resource use for nontraumatic problems. METHODS: We studied all Canadian Armed Forces (CAF) members deployed to Afghanistan between Feb. 7, 2006, and June 30, 2011, who required treatment for a nontraumatic general surgical condition. RESULTS: During the study period 28 990 CAF personnel deployed to Afghanistan; 373 (1.28%) were repatriated because of disease and 100 (0.34%) developed an acute general surgical condition. Among those who developed an acute surgical illness, 42 were combat personnel (42%) and 58 were support personnel (58%). Urologic diagnoses (n = 34) were the most frequent acute surgical conditions, followed by acute appendicitis (n = 18) and hernias (n = 12). We identified 5 areas where intensified predeployment screening could have potentially decreased the incidence of in-theatre acute surgical illness. CONCLUSION: Our findings suggest that there is a significant acute care surgery element encountered on combat deployment, and surgeons tasked with caring for this population should be prepared to treat these patients.

CONTEXTE: Il y a un manque de données sur les problèmes chirurgicaux aigus qui peuvent survenir lors de déploiements militaires, et encore moins sur la question de savoir si on aurait pu éviter ces problèmes en faisant un dépistage plus ciblé avant le déploiement. Nous avons tenté de déterminer le fardeau de la maladie attribuable à des problèmes non traumatiques aigus de chirurgie générale pendant le déploiement, puis d'identifier les domaines où un dépistage préalable plus rigoureux pourrait être mis en oeuvre pour réduire l'utilisation des ressources chirurgicales pour les problèmes non traumatiques. MÉTHODES: Notre étude a porté sur tous les membres des Forces armées canadiennes (FAC) déployés en Afghanistan entre le 7 février 2006 et le 30 juin 2011 et qui ont eu besoin de traitement pour un état chirurgical général non traumatique. RÉSULTANTS: Pendant la période de l'étude, 28 990 membres des FAC ont été déployés en Afghanistan; 373 (1,28 %) ont été rapatriés en raison de maladie et 100 (0,34 %) ont développé un état chirurgical général aigu. Parmi ces derniers, 42 faisaient partie du personnel de combat (42 %) et 58 faisaient partie du personnel de soutien (58 %). Les diagnostics urologiques (n = 34) constituaient les états chirurgicaux aigus les plus fréquents, suivis de l'appendicite aiguë (n = 18) et des hernies (n = 12). Nous avons identifié 5 domaines où un dépistage intensifié, préalable au déploiement, aurait possiblement réduit l'incidence des états chirurgicaux aigus en théâtre d'opérations. CONCLUSION: Il ressort de nos conclusions que les missions de combat comportent un important élément de soins chirurgicaux aigus et que les chirurgiens chargés de soigner cette population devraient être préparés à traiter ces patients.

Advances in damage control resuscitation and surgery: implications on the organization of future military field forces.

Medical support to deployed field forces is increasingly becoming a shared responsibility among allied nations. National military medical planners face several key challenges, including fiscal restraints, raised expectations of standards of care in the field and a shortage of appropriately trained specialists. Even so, medical services are now in high demand, and the availability of medical support may become the limiting factor that determines how and where combat units can deploy. The influence of medical factors on operational decisions is therefore leading to an increasing requirement for multinational medical solutions. Nations must agree on the common standards that govern the care of the wounded. These standards will always need to take into account increased public expectations regarding the quality of care. The purpose of this article is to both review North Atlantic Treaty Organization (NATO) policies that govern multinational medical missions and to discuss how recent scientific advances in prehospital battlefield care, damage control resuscitation and damage control surgery may inform how countries within NATO choose to organize and deploy their field forces in the future.

De plus en plus, la responsabilité du soutien médical offert aux forces militaires déployées sur le terrain devient partagée entre les nations alliées. Les planificateurs médicaux militaires nationaux font face à plusieurs défis importants, tels que restrictions budgétaires, attentes élevées au chapitre des normes de soin sur le terrain et pénurie de spécialistes dûment formés. Malgré cela, les services médicaux sont présentement en grande demande et leur disponibilité pourrait devenir le facteur limitatif susceptible de déterminer de quelle façon et en quels lieux les unités de combat peuvent se déployer. L'impact des facteurs médicaux sur les décisions opérationnelles requiert donc de plus en plus des solutions médicales multinationales. Les nations doivent s'entendre sur des normes communes qui régissent les soins à prodiguer aux blessés. Ces normes devront toujours tenir compte des attentes accrues du public en regard de la qualité des soins. Le but de cet article est de revoir les politiques de l'Organisation du Traité de l'Atlantique Nord (OTAN) qui régissent les missions médicales multinationales et de discuter de la façon dont les progrès scientifiques récents des soins pré-hospitaliers sur les champs de bataille et les techniques de réanimation et de chirurgie de sauvetage peuvent éclairer la façon dont les pays de l'OTAN décideront d'organiser et de déployer leurs forces sur le terrain à l'avenir.

Re-evaluating the field tourniquet for the Canadian Forces.

OBJECTIVE: To determine the best field tourniquet for Medical Technician (Med Tech) use in the Canadian Forces (CF). METHODS: We conducted a prospective controlled trial, comparing the efficacy and ease of applicability of 3 types of commercially available windlass tourniquets in 4 tactical situations on simulated patients. The primary outcome was time to tourniquet application with secondary outcomes including effectiveness and Med Tech satisfaction. RESULTS: The overall finding of this study indicates that the Combat Application Tourniquet (C-A-T) was applied the fastest in each scenario and was also significantly the most effective in occluding distal blood flow. The survey results show that the 3 tourniquet types are similar in many of the measures of ease of learning and application, with the C-A-T scoring highest in self-application and the Special Operations Forces Tactical Tourniquet Wide having the lowest scores for both durability and effectiveness. CONCLUSION: When tested on a group of CF Med Techs, the C-A-T remained the CF field tourniquet of choice, based on the assessed criteria. Although there is inherent bias in the approach of this study, it reflects the process required to determine if a new piece of kit is superior to what is already considered the standard to a trained and equipped military.

Causes of death in Canadian Forces members deployed to Afghanistan and implications on tactical combat casualty care provision.

BACKGROUND: As part of its contribution to the Global War on Terror and North Atlantic Treaty Organization's International Security Assistance Force, the Canadian Forces deployed to Kandahar, Afghanistan, in 2006. We have studied the causes of deaths sustained by the Canadian Forces during the first 28 months of this mission. The purpose of this study was to identify potential areas for improving battlefield trauma care. METHODS: We analyzed autopsy reports of Canadian soldiers killed in Afghanistan between January 2006 and April 2008. Demographic characteristics, injury data, location of death within the chain of evacuation, and cause of death were determined. We also determined whether the death was potentially preventable using both explicit review and implicit review by a panel of trauma surgeons. RESULTS: During the study period, 73 Canadian Forces members died in Afghanistan. Their mean age was 29 (+/-7) years and 98% were male. The predominant mechanism of injury was explosive blast, resulting in 81% of overall deaths during the study period. Gunshot wounds and nonblast-related motor vehicle collisions were the second and third leading mechanisms of injury causing death. The mean Injury Severity Score was 57 (+/-24) for the 63 study patients analyzed. The most common cause of death was hemorrhage (38%), followed by neurologic injury (33%) and blast injuries (16%). Three deaths were deemed potentially preventable on explicit review, but implicit review only categorized two deaths as being potentially preventable. CONCLUSIONS: The majority of combat-related deaths occurred in the field (92%). Very few deaths were potentially preventable with current Tactical Combat Casualty interventions. Our panel review identified several interventions that are not currently part of Tactical Combat Casualty that may prevent future battlefield deaths.

Needle decompression for tension pneumothorax in Tactical Combat Casualty Care: do catheters placed in the midaxillary line kink more often than those in the midclavicular line?

BACKGROUND: Tactical Combat Casualty Care (TCCC) is a system of prehospital trauma care designed for the combat environment. Needle decompression (ND) is a critical TCCC intervention, because previous data suggest that up to 33% of all preventable deaths on the battlefield result from tension pneumothoraces. There has recently been increased interest in performing ND at the fifth intercostal space in the midaxillary line to prevent complications associated with landmarking second intercostal space in the midclavicular line site. We developed a model to assess whether catheters placed in the midaxillary line for decompressing tension pneumothoraces are more prone to kinking than those placed in the midclavicular line because of adducted arms during military transport. METHODS: To simulate ND, we secured segments of porcine chest walls over volunteer soldiers' chests and placed 14-gauge, 1.5-inch angiocatheters through the porcine wall segments which were affixed to either the midaxillary or midclavicular location on the volunteers. We then assessed for occlusion and kinking by flow of normal saline (NS) through the angiocatheter in situ. The angiocatheter was then transduced using standard arterial line manometry, and the opening pressures required to initiate flow through the catheters were measured. The opening pressures were then converted to mm Hg. We also assessed for catheter occlusion after the physical manipulation of the patient, by simulated patient transport. RESULTS: We observed that there was a significant pressure difference required to achieve free flow through the in situ angiocatheter between the fifth intercostal space midaxillary line versus the second intercostal space midclavicular line site (13.1 ± 3.6 mm Hg vs. 7.9 ± 1.8 mm Hg). CONCLUSIONS: This study suggests that the 14-gauge, 1.5-inch angiocatheter used for ND in the midaxillary line may partially and temporarily occlude in patients who will be transported on military stretchers. The pressure of 12.8 mm Hg has been documented in animal models as the pressure at which hemodynamic instability develops. This may contribute to the reaccumulation of tension pneumothoraces and ultimate patient deterioration in military transport.

Spinal injuries after improvised explosive device incidents: implications for Tactical Combat Casualty Care.

BACKGROUND: Tactical Combat Casualty Care aims to treat preventable causes of death on the battlefield but deemphasizes the importance of spinal immobilization in the prehospital tactical setting. However, improvised explosive devices (IEDs) now cause the majority of injuries to Canadian Forces (CF) members serving in Afghanistan. We hypothesize that IEDs are more frequently associated with spinal injuries than non-IED injuries and that spinal precautions are not being routinely employed on the battlefield. METHODS: We examined retrospectively a database of all CF soldiers who were wounded and arrived alive at the Role 3 Multinational Medical Unit in Kandahar, Afghanistan, from February 7, 2006, to October 14, 2009. We collected data on demographics, injury mechanism, anatomic injury descriptions, physiologic data on presentation, and prehospital interventions performed. Outcomes were incidence of any spinal injuries. RESULTS: Three hundred seventy-two CF soldiers were injured during the study period and met study criteria. Twenty-nine (8%) had spinal fractures identified. Of these, 41% (n = 12) were unstable, 31% (n = 9) stable, and 28% indeterminate. Most patients were injured by IEDs (n = 212, 57%). Patients injured by IEDs were more likely to have spinal injuries than those injured by non-IED-related mechanisms (10.4% vs. 2.3%; p < 0.01). IED victims were even more likely to have spinal injuries than patients suffering blunt trauma (10.4% vs. 6.7%; p = 0.02). Prehospital providers were less likely to immobilize the spine in IED victims compared with blunt trauma patients (10% [22 of 212] vs. 23.0% [17 of 74]; p < 0.05). CONCLUSIONS: IEDs are a common cause of stable and unstable spinal injuries in the Afghanistan conflict. Spinal immobilization is an underutilized intervention in the battlefield care of casualties in the conflict in Afghanistan. This may be a result of tactical limitations; however, current protocols should continue to emphasize the judicious use of immobilization in these patients.

Tactical combat casualty care in the Canadian Forces: lessons learned from the Afghan war.

Tactical Combat Casualty Care (TCCC) is intended to treat potentially preventable causes of death on the battlefield, but acknowledges that application of these treatments may place the provider and even the mission in jeopardy if performed at the wrong time. Therefore, TCCC classifies the tactical situation with respect to health care provision into 3 phases (care under fire, tactical field care and tactical evacuation) and only permits certain interventions to be performed in specific phases based on the danger to the provider and casualty. In the 6 years that the Canadian Forces (CF) have been involved in sustained combat operations in Kandahar, Afghanistan, more than 1000 CF members have been injured and more than 150 have been killed. As a result, the CF gained substantial experience delivering TCCC to wounded soldiers on the battlefield. The purpose of this paper is to review the principles of TCCC and some of the lessons learned about battlefield trauma care during this conflict.