Cold Finger: Raynaud Phenomenon Following Snakebite Envenoming by Nikolsky's Viper (Vipera berus nikolskii).

A field biologist was bitten by a female Nikolsky's viper (Vipera berus nikolskii) in Kharkiv Oblast, Ukraine. Two months later, the patient began to experience cold-induced vasospasm of the affected digit diagnosed as acquired Raynaud phenomenon. The patient had more than 30 occurrences during the single winter following the bite, but the signs and symptoms of Raynaud phenomenon disappeared with the end of winter. This report describes the case and puts it into context with the literature on the topic of toxin-induced peripheral vasospastic disorders and their potential importance in snakebite envenoming.

Tragedy into drama: an american history of tourniquet use in the current war.

BACKGROUND: Although the scientific results of recent tourniquet advances in first aid are well recorded, the process by which tourniquet use advances were made is not. The purpose of the present report is to distill historical aspects of this tourniquet story during the current wars in Afghanistan and Iraq to aid scientists, leaders, and clinicians in the process of development of future improvements in first aid. METHODS: The process of how developments of this tourniquet story happened recently is detailed chronologically and thematically in a ?who did what, when, where, why, and how? way. RESULTS: Initially in these wars, tourniquets were used rarely or were used as a means of last resort. Such delay in tourniquet use was often lethal; subsequently, use was improved incrementally over time by many people at several organizations. Three sequential keys to success were (1) unlocking the impasse of enacting doctrinal ideas already approved, (2) reaching a critical density of both tourniquets and trained users on the battlefield, and (3) capturing their experience with tourniquets. Other keys included translating needs among stakeholders (such as casualties, combat medics, providers, trainers, and decision-makers) and problem-solving logistic snags and other issues. Eventually, refined care was shown to improve survival rates. From all medical interventions evidenced in the current wars, the tourniquet broke rank and moved to the forefront as the prehospital medical breakthrough of the war. CONCLUSION: The recorded process of how tourniquet developments in prehospital care occurred may be used as a reference for parallel efforts in first aid such as attempts to improve care for airway and breathing problems.

Analysis of recovered tourniquets from casualties of Operation Enduring Freedom and Operation New Dawn.

BACKGROUND: Tourniquet use recently became common in war, but knowledge gaps remain regarding analysis of recovered devices. The purpose of this study was to analyze tourniquets to identify opportunities for improved training. METHODS: We analyzed tourniquets recovered from deceased service members serving in support of recent combat operations by a team at Dover Air Force Base from 2010 to 2012. Device makes and models, breakage, deformation, band routing, and windlass turn numbers were counted. RESULTS: We recovered 824 tourniquets; 390 were used in care and 434 were carried unused. Most tourniquets were recommended by the Committee on Tactical Combat Casualty Care (Combat Application Tourniquet [CAT] or Special Operations Forces Tactical Tourniquet). The band was routed once through the buckle in 37% of used CATs, twice in 62%, and 1% had none. For tourniquets with data, the windlass turn number averaged 3.2 (range, 0-9). The CAT windlass turn number was associated positively with tourniquet deformation as moderate or severe deformation began at 2 turns, increased in likelihood stepwise with each turn, and became omnipresent at 7 or more. CONCLUSIONS: Tourniquet counts, band routings, windlass turn numbers, and deformation rates are candidate topics for instructors to refine training.

Development of a standard swine hemorrhage model for efficacy assessment of topical hemostatic agents.

BACKGROUND: The diverse information of efficacy of hemostatic products, obtained from different military laboratories using different models, has made it difficult to ascertain the true benefit of new hemostatic agents in military medicine. The aim of this study was to recommend a standard hemorrhage model for efficacy testing acceptable by most investigators in the field and avoid contradictory and duplicative efforts by different laboratories. METHODS: The swine femoral artery injury model (6-mm arteriotomy) with some modifications was tested to standardize the model. The suggested modifications included no splenectomy, one-time treatment, 30 seconds free bleeding, and 5 L limit for fluid resuscitation. The model was tested with all or some of these modifications in four experimental conditions (n = 5-6 pigs per condition) using Combat Gauze (CG) as control agent. RESULTS: The primary end points including blood pressure, blood loss, and survival rates were modestly changed in the four conditions. The second experimental condition in which bleeding was treated with a single CG with 3-minute compression produced the most suitable results. The average blood loss was 99 mL/kg, and hemostasis was achieved in one-third of the pigs, which led to matching survival rate. CONCLUSION: A rigorous hemorrhage model was developed for future evaluation of new hemostatic agents and comparison with CG, the current standard of care. This model may not be suitable for testing every agent and some modifications may be necessary for specific applications. Furthermore, laboratory studies using this or similar models must be accompanied by operational testing in the field to confirm the efficacy and practical utility of selected agents when used on the battlefield.

Feedback to the field: an assessment of sternal intraosseous (IO) infusion.

Intraosseous vascular infusion (IO) is a recognized alternative to peripheral intravenous infusion when access is inadequate. The sternum and proximal tibia are the preferred sites. A review of 98 cases at autopsy revealed successful sternal IO placement in 78 cases (80%). Assuming a worst case scenario for placement (pin mark and no tip in bone [17 cases] and tip present and not in the sternum [3 cases]), attempts were unsuccessful in 20 cases (20%). We draw no specific conclusions regarding sternal IO use, but hope that personnel placing these devices and those providing medical training can use the information.