Targeted metagenomic assessment reflects critical colonization in battlefield injuries.

IMPORTANCE: Microbial contamination in combat wounds can lead to opportunistic infections and adverse outcomes. However, current microbiological detection has a limited ability to capture microbial functional genes. This work describes the application of targeted metagenomic sequencing to profile wound bioburden and capture relevant wound-associated signatures for clinical utility. Ultimately, the ability to detect such signatures will help guide clinical decisions regarding wound care and management and aid in the prediction of wound outcomes.

Resistance patterns and clinical outcomes of Klebsiella pneumoniae and invasive Klebsiella variicola in trauma patients.

Recent reclassification of the Klebsiella genus to include Klebsiella variicola, and its association with bacteremia and mortality, has raised concerns. We examined Klebsiella spp. infections among battlefield trauma patients, including occurrence of invasive K. variicola disease. Klebsiella isolates collected from 51 wounded military personnel (2009-2014) through the Trauma Infectious Disease Outcomes Study were examined using polymerase chain reaction (PCR) and pulsed-field gel electrophoresis. K. variicola isolates were evaluated for hypermucoviscosity phenotype by the string test. Patients were severely injured, largely from blast injuries, and all received antibiotics prior to Klebsiella isolation. Multidrug-resistant Klebsiella isolates were identified in 23 (45%) patients; however, there were no significant differences when patients with and without multidrug-resistant Klebsiella were compared. A total of 237 isolates initially identified as K. pneumoniae were analyzed, with 141 clinical isolates associated with infections (remaining were colonizing isolates collected through surveillance groin swabs). Using PCR sequencing, 221 (93%) isolates were confirmed as K. pneumoniae, 10 (4%) were K. variicola, and 6 (3%) were K. quasipneumoniae. Five K. variicola isolates were associated with infections. Compared to K. pneumoniae, infecting K. variicola isolates were more likely to be from blood (4/5 versus 24/134, p = 0.04), and less likely to be multidrug-resistant (0/5 versus 99/134, p<0.01). No K. variicola isolates demonstrated the hypermucoviscosity phenotype. Although K. variicola isolates were frequently isolated from bloodstream infections, they were less likely to be multidrug-resistant. Further work is needed to facilitate diagnosis of K. variicola and clarify its clinical significance in larger prospective studies.

Point-of-care ultrasound for treatment and triage in austere military environments.

BACKGROUND: Assessment and triage in an austere environment represent a major challenge in casualty care. Modern conflicts involve a significant proportion of multiple wounds, either superficial or penetrating, which complicate clinical evaluation. Furthermore, there is often poor accessibility to computed tomography scans and a limited number of surgical teams. Therefore, ultrasound (US) represents a potentially valuable tool for distinguishing superficial fragments or shrapnels from penetrating trauma requiring immediate damage-control surgery. METHODS: This retrospective observational multicenter study assessed casualties treated for 8 months by five medical teams deployed in Africa and Middle East. Two experts, who were experienced in military emergency medicine but did not take part in the missions, carried out an independent analysis for each case, evaluating the contribution of US to the following five items: triage categorization, diagnosis, clinical severity, prehospital therapeutic choices, and priority to operation room. Consensus was obtained using the Delphi method with three rounds. RESULTS: Of 325 casualties, 189 underwent US examination. The mean injury severity scale score was 25.6, and 76% were wounded by an improvised explosive device. Ultrasound was useful for confirming (23%) or excluding (63%) the suspected diagnosis made in the clinical assessment. It also helped obtain a diagnosis that had not been considered for 3% of casualties and was responsible for a major change in procedure or therapy in 4%. Ultrasound altered the surgical priority in 43% of cases. For 30% of cases, US permitted surgery to be temporarily delayed to prioritize another more urgent casualty. CONCLUSION: Ultrasound is a valuable tool for the management of mass casualties by improving treatment and triage, especially when surgical resources are limited. In some situations, US can also correct a diagnosis or improve prehospital therapeutic choices. Field medical teams should be trained to integrate US into their prehospital protocols. LEVEL OF EVIDENCE: Case series (no criterion standard), level V.

Military service and related risk factors for amyotrophic lateral sclerosis.

BACKGROUND: The cause of amyotrophic lateral sclerosis (ALS) is unknown, but occupations have been explored as a potential proxy measure of risk. There is a substantial body of literature connecting military service to ALS. We aimed to summarize and assess the quality of this evidence. METHODS: Systematic review of the literature, including observational studies which explored one of the following exposures: general military service (army, air force, marines, or navy); or specific exposures associated with military service measured among military personnel. The outcome of interest was ALS incidence, which could include onset, diagnosis, or death from ALS. RESULTS: A total of 2642 articles were screened. Following exclusion, 19 articles remained for inclusion in the systematic review, including 1 meta-analysis and 18 original observational studies. Most studies were of moderate quality. In general, the relationship between military service was suggestive of an increased risk, particularly among Gulf War and WWII veterans. Exposure to pesticides (including Agent Orange) certain chemicals (exhaust, burning agents), heavy metals, and head trauma appeared to increase the risk of ALS among military personnel. CONCLUSIONS: There is a possible association between military service and the subsequent development of ALS; however, the evidence was limited. Studies were generally hindered by small sample sizes and inadequate follow-up time. Future studies should endeavor to objectively measure specific exposures, or combinations thereof, associated with military service, as this will be of vital importance in implementing preventative strategies into military organizations.

Outcomes of Exploratory Laparotomy and Abdominal Infections Among Combat Casualties.

BACKGROUND: Abdominal injuries historically account for 13% of battlefield surgical procedures. We examined the occurrence of exploratory laparotomies and subsequent abdominal surgical site infections (SSIs) among combat casualties. METHODS: Military personnel injured during deployment (2009-2014) were included if they required a laparotomy for combat-related trauma and were evacuated to Landstuhl Regional Medical Center, Germany, before being transferred to participating US military hospitals. RESULTS: Of 4304 combat casualties, 341 (7.9%) underwent laparotomy. Including re-explorations, 1053 laparotomies (median, 2; interquartile range, 1-3; range, 1-28) were performed with 58% occurring within the combat zone. Forty-nine (14.4%) patients had abdominal SSIs (four with multiple SSIs): 27 (7.9%) with deep space SSIs, 14 (4.1%) with a deep incisional SSI, and 12 (3.5%) a superficial incisional SSI. Patients with abdominal SSIs had larger volume of blood transfusions (median, 24 versus 14 units), more laparotomies (median, 4 versus 2), and more hollow viscus injuries (74% versus 45%) than patients without abdominal SSIs. Abdominal closure occurred after 10 d for 12% of the patients with SSI versus 2% of patients without SSI. Mesh adjuncts were used to achieve fascial closure in 20.4% and 2.1% of patients with and without SSI, respectively. Survival was 98% and 96% in patients with and without SSIs, respectively. CONCLUSIONS: Less than 10% of combat casualties in the modern era required abdominal exploration and most were severely injured with hollow viscus injuries and required massive transfusions. Despite the extensive contamination from battlefield injuries, the SSI proportion is consistent with civilian rates and survival was high.

Association of War-Related and Gender-Based Violence With Mental Health States of Yazidi Women.

Importance: Yazidi women in northern Iraq have experienced severe human rights violations through attacks by the so-called Islamic State group, with severe consequences for their health. However, no studies to date have investigated how war-related and gender-based violence, including partner violence, are associated with mental health disorders in this population. Objective: To evaluate the associations between Yazidi women's experiences of violence (ie, war violence, partner violence, enslavement) and their mental health. Design, Setting, and Participants: This cross-sectional study of 326 women was conducted in camps for displaced persons in the Kurdistan region of Iraq between January and July 2017. Participants were married women from the Yazidi population in northern Iraq who were affected by Islamic State attacks. Participants were selected via household-randomized sampling. Data analysis was conducted from December 2018 to September 2019. Exposures: Experiences of enslavement, war-related events, and intimate partner violence were measured with event checklists. Main Outcomes and Measures: Posttraumatic stress disorder (PTSD) and depression levels were measured using culturally validated instruments. Results: A total of 326 women (mean [SD] age, 34.3 [12.9] years) participated in the study. Almost all participants reported the experience of at least 1 war-related violent event (325 [99.7%]), 54 (16.6%) reported a history of abduction and sexual slavery, and 215 (66.0%) reported the experience of at least 1 type of intimate partner violence in the past year. There were no significant differences between women who did and did not experience abduction regarding exposure to intimate partner violence. Rates of PTSD and depression symptoms were high among the whole sample, and women who experienced abduction reported significantly higher levels of psychopathology than those who did not (mean [SD] PTSD score: 61.48 [12.38] vs 47.61 [14.42]; t324 = -6.91; P < .001; mean [SD] depression score: 3.07 [0.68] vs 2.43 [0.68]; t324 = -6.78; P < .001). Multivariate hierarchical regressions revealed that psychopathology was associated with exposure to war-related events (PTSD: ß = 0.29; P < .001; depression: ß = 0.27; P < .001) as well as with exposure to gender-based violence in Islamic State captivity (PTSD: ß = 0.19; P = .001; depression: ß = 0.28, P < .001) and in their marriage (PTSD: ß = 0.13; P = .008; depression: ß = 0.18; P < .001). Conclusions and Relevance: In this study, interviewed Yazidi women often experienced intimate partner violence as well as war-related and gender-based violence under Islamic State attacks and enslavement, experiences that were associated with mental health impairment. The findings underline the importance of also addressing gender-based violence within health care approaches for war-affected populations.

Noninvasive SpO2/FiO2 ratio as surrogate for PaO2/FiO2 ratio during simulated prolonged field care and ground and high-altitude evacuation.

BACKGROUND: Diagnosis of lung injury requires invasive blood draws to measure oxygen tension in blood. This capability is nonexistent in austere settings and during prolonged field care (PFC), that is, medical care characterized by inability to evacuate casualties from the point of injury for up to 72 hours. We analyzed pulse-oximeter-derived noninvasive SpO2 and assessed the SpO2/FiO2 ratio (SFR) as a surrogate for the PaO2/FiO2 ratio (PFR), an accepted marker of lung function. We hypothesized that SFR is a suitable surrogate for PFR in a data set from animal models of combat-relevant trauma, PFC, and aeromedical evacuation. METHODS: Data from anesthetized swine (N = 30) subjected to combat relevant trauma, resuscitation, and critical care interventions were analyzed. Pairwise correlations and Bland-Altman and regression analyses were performed to compare PFR and SFR, based on averaged SpO2 values obtained from two monitoring devices. RESULTS: We performed 683 pairwise correlations. SpO2/FiO2 ratio was numerically higher than PFR with a 313 cutoff values for acute respiratory distress syndrome (ARDS) (PFR ≥300). Sensitivity/specificity for detection of mild ARDS was 75%/73% with a 200 to 300 PFR range corresponding to 252 to 312 SFR range. For moderate ARDS, sensitivity/specificity was 61%/93% with a 100 to 200 PFR range corresponding to 191 to 251 SFR range. For severe ARDS, sensitivity/specificity was 49%/97% with a 0 to 100 PFR range corresponding to 0 to 190 SFR range. For all groups, areas under the receiver operating characteristic curves ranged from 0.76 to 0.98. CONCLUSION: SpO2/FiO2 ratio is a useful surrogate for PFR when arterial blood gas testing is not available during dynamically changing physiologic conditions, for example, during austere conditions, PFC, or aeromedical evacuation, and may permit early detection of casualties in need of lung-specific life-saving interventions. Studies in critically ill humans are warranted.

Combat medic testing of a novel monitoring capability for early detection of hemorrhage.

BACKGROUND: Current out-of-hospital protocols to determine hemorrhagic shock in civilian trauma systems rely on standard vital signs with military guidelines relying on heart rate and strength of the radial pulse on palpation, all of which have proven to provide little forewarning for the need to implement early intervention prior to decompensation. We tested the hypothesis that addition of a real-time decision-assist machine-learning algorithm, the compensatory reserve measurement (CRM), used by combat medics could shorten the time required to identify the need for intervention in an unstable patient during a hemorrhage profile as compared with vital signs alone. METHODS: We randomized combat medics from the Army Medical Department Center and School Health Readiness Center of Excellence into three groups: group 1 viewed a display of no simulated hemorrhage and unchanging vital signs as a control (n = 24), group 2 viewed a display of simulated hemorrhage and changing vital signs alone (hemorrhage; n = 31), and group 3 viewed a display of changing vital signs with the addition of the CRM (hemorrhage + CRM; n = 22). Participants were asked to push a computer key when they believed the patient was becoming unstable and needed medical intervention. RESULTS: The average time of 11.0 minutes (95% confidence interval, 8.7-13.3 minutes) required by the hemorrhage + CRM group to identify an unstable patient (i.e., stop the video sequence) was less by more than 40% (p < 0.01) compared with 18.9 minutes (95% confidence interval, 17.2-20.5 minutes) in the hemorrhage group. CONCLUSION: The use of a machine-learning monitoring technology designed to measure the capacity to compensate for central blood volume loss resulted in reduced time required by combat medics to identify impending hemodynamic instability. LEVEL OF EVIDENCE: Diagnostic, level IV.

Blessés de guerres dans un centre de santé de cercle au Mali : profil épidémio-clinique et prise en charge

But : Décrire les aspects épidémiologiques, cliniques et thérapeutiques des blessures de guerres au centre de santé de référence de Douentza. Patients et Méthode : Il s'agissait d'une étude descriptive incluant les patients pris en charge entre le 1er Décembre 2017 et le 31 Décembre 2018 au centre de santé de référence du district sanitaire de Douentza. La stratégie de prise en charge des blessés adoptée était celle de MARCHE et selon les principes de la chirurgie de guerre. Résultats Au total nous avons reçu 71 blessés de guerre au centre de santé de Douentza. Cette série était composée de 66 hommes, de 34 (48%) militaires et représentait 63% des urgences chirurgicales (n=113) et 30% des interventions chirurgicales réalisées dans l'établissement. Les lésions siégeaient sur les membres dans 53% des cas; 23% sur l'abdomen (traumatismes abdominaux pénétrant et/ou perforants) et 15% sur la région dorso-lombaire. Elles étaient causées par des engins explosifs improvisés (48%), des balles (37%) et des armes blanches (15%). Il s'agissait de plaies abdominales dans 11 cas (16%) dont 4 plaies perforantes et 7 plaies non pénétrantes, de plaies vasculaires dans 7 cas (10%), de délabrements cutanéo-musculaires dans 21 cas (30%), de broiements de la main dans 1 cas et d'écrasement également dans 1 cas (1%). Les lésions étaient infectées à l'admission dans 25% des cas et un état de choc était retrouvé chez 15% des patients. 68% des patients étaient référés dans une structure plus équipée pour prise en charge appropriée. L'échographie seul examen para clinique disponible, était utilisée 33 fois (46%) pour explorer l'abdomen. Elle était contributive au diagnostic 11 fois (33%). Sur le plan thérapeutique, le parage chirurgical était d'emblée réalisé chez 53 patients (75%). 16 décès (23%) ont été déplorés, suites à des traumatismes cranio-cérébraux (n=2), plaie cervicale (n=1), péritonites (n=3), polytraumatisme (n=1) et 9 décès ont été constatés à l'admission. Conclusion Les blessés de guerre sont des urgences chirurgicales graves menaçant le pronostic vital immédiat et/ou fonctionnel à long terme. Leur prise en charge exige une organisation et des équipements spécifiques. Le centre de santé de Douentza à l'instar des autres centres de santé du Mali, disposant d'un faible plateau technique et sans plan d'urgence s'est trouvé confronté à l'accueil d'un nombre croissant de blessés de guerre pour lesquels, il n'était pas préparé. La gestion de ces blessés a été difficile d'où la nécessité de repenser les missions des centres de santé de cercle et le niveau de leur plateau technique

A review of early warning systems for prompt detection of patients at risk for clinical decline.

Early Warning Scores (EWS) are a composite evaluation of a patient's basic physiology, changes of which are the first indicators of clinical decline and are used to prompt further patient assessment and when indicated intervention. These are sometimes referred to as "track and triggers systems" with tracking meant to denote periodic observation of physiology and trigger being a predetermined response criteria. This review article examines the most widely used EWS, with special attention paid to those used in military and trauma populations.The earliest EWS is the Modified Early Earning Score (MEWS). In MEWS, points are allocated to vital signs based on their degree of abnormality, and summed to yield an aggregate score. A score above a threshold would elicit a clinical response such as a rapid response team. Modified Early Earning Score was subsequently followed up with the United Kingdom's National Early Warning Score, the electronic cardiac arrest triage score, and the 10 Signs of Vitality score, among others.Severity of illness indicators have been in military and civilian trauma populations, such as the Revised Trauma Score, Injury Severity Score, and Trauma and Injury Severity. The sequential organ failure assessment score and its attenuated version quick sequential organ failure assessment were developed to aggressively identify patients near septic shock.Effective EWS have certain characteristics. First, they should accurately capture vital signs information. Second, almost all data should be derived electronically rather than manually. Third, the measurements should take into consideration multiple organ systems. Finally, information that goes into an EWS must be captured in a timely manner. Future trends include the use of machine learning to detect subtle changes in physiology and the inclusion of data from biomarkers. As EWS improve, they will be more broadly used in both military and civilian environments. LEVEL OF EVIDENCE: Review article, level I.

Thoracic trauma in military settings: a review of current practices and recommendations.

PURPOSE OF REVIEW: To examine current literature on thoracic trauma related to military combat and to explore its relevance to the civilian population. RECENT FINDINGS: Damage control resuscitation (DCR) has improved the management of hemorrhaging trauma patients. Permissive hypotension below 110 mmHg and antifibrinolytic use during DCR is widely accepted, whereas the use of freeze-dried plasma and whole blood is gaining popularity. The Modified Physiologic Triaging Tool can be used for primary triage and it may have applications in civilian trauma systems. Although Tactical Combat Casualty Care protocol recommends the Cric-Key device for surgical cricothyroidotomies, other devices may offer comparable performance. Recommendations for regional anesthesia after blunt trauma are not well defined. Increasing amounts of evidence favor the use of extracorporeal membrane oxygenation for refractory hypoxemia and resuscitative endovascular balloon occlusion of the aorta (REBOA) for severe hemorrhage. REBOA outcomes are potentially improved by partial occlusion and small 7 Fr catheters. SUMMARY: The Global War on Terror has provided opportunities to better understand and treat thoracic trauma in military settings. Trauma registries and other data sources have contributed to significant advancements in the management of thoracic trauma in military and civilian populations.

Missed injuries in combat casualties: Lessons from Iraq and Afghanistan.

INTRODUCTION: Once injured in the battlefield in Iraq and Afghanistan, U.S. and NATO troops receive medical treatment through tiered echelons of care with varying resources, from austere to state-of-the-art. Similar to civilian trauma systems, the aim is to provide rapid and safe patient movement toward definitive management. A consequence of the rapid transfer of patients is the possibility of missed or delayed diagnosis of injuries. With the new injury patterns seen during these conflicts, we aimed to identify and characterize which injuries are missed and what consequences do they have on our troops' road to recovery. PATIENTS AND METHODS: A retrospective review of a PI database (established 2007) for consecutively admitted combat casualties was performed between 2007-2013. Baseline patient characteristics, injury year, admitting service, injury type, and subsequent management decisions were categorized and analyzed. RESULTS: There were 301 missed injuries (MI) identified in 248 patients. The annual missed injury rate was 25 per 1000 admissions. Missed injuries were associated with a penetrating mechanism (82.7% vs 58.5%, p < 0.001), ICU admission (58.5% vs 27.4%, p < 0.001), higher ISS (median 14 vs 8, p < 0.001), and a longer length of stay (median 3 versus 2 days, p < 0.001). 194 (64.5%) missed injuries led to a change in management, with 68 (22.6%) requiring a surgical procedure. 1.3% of missed injuries were life threatening, 28.2% major and 65.4% minor. The most common injuries were distal extremity fractures (23.9%), followed by spine fractures (13.3%) and traumatic tympanic membrane rupture (12.6%), There were no deaths attributed to a missed injury. DISCUSSION: Missed injuries during combat operations occur on a low but consistent basis. Most injuries are orthopedic in nature and typically occur in critically ill patients admitted to the ICU. It is rare that a missed injury results in a life-threatening condition. CONCLUSION: As healthcare practitioners prepare for future deployments, this analysis may serve as a resource to focus on frequently missed injuries and possibly improve their detection.

Can functional emotion regulation protect children's mental health from war trauma? A Palestinian study.

Effective emotion regulation (ER) is expected to protect mental health in traumatic stress. We first analysed the protective (moderator) function of different ER strategies and the associations between ER and mental health. Second, we tested gender differences in the protective function of ER and the associations between ER strategies and mental health. Participants were 482 Palestinian children (girls 49.4%; 10-13 years, M = 11.29, SD = .68) whose ER was assessed by the Emotion Regulation Questionnaire and mental health by post-traumatic stress (Children's Impact Event Scale), depressive, and psychological distress (Strengths and Difficulties Questionnaire) symptoms, and by psychosocial well-being (Mental Health Continuum-Short Form). War trauma involved 42 events. Results showed, first, that none of the ER strategies could protect a child's mental health from negative impact of war trauma, but self-focused ER was associated with low depressive symptoms, and other-facilitated ER with high psychological well-being. However, controlling of emotions formed a comprehensive risk for children's mental health. Second, gender differences were found in the protective role of ER, as self-focused and distractive ER formed a vulnerability among boys. The results are discussed in the context of emotional and regulative demands of war and life-threat.

Prehospital Airway Management in Iraq and Afghanistan: A Descriptive Analysis.

OBJECTIVES: Airway failures are the second leading cause of potentially preventable death on the battlefield. Improvements in airway management depend on identifying current challenges. We sought to build on previously reported data on prehospital, combat airway management. METHODS: We used a series of emergency department procedure codes to identify patients within the Department of Defense Trauma Registry from January 2007 to August 2016. This is a subanalysis of those with a documented prehospital airway intervention. RESULTS: Of the 28,222 patients in our dataset, 1379 (4.9%) had a documented prehospital airway intervention. Airway devices consisted of 49 airway adjuncts (17 nasopharyngeal airways, 2 oropharyngeal airways, remainder listed as unspecified), 230 cricothyrotomies, 1117 endotracheal intubations, and 27 supraglottic airways. Patients undergoing airway intervention were mostly members of the US military (42.2%). Compared with those without airway intervention, they were slightly younger (median 24 vs 25 years, P < 0.001), more frequently injured by explosives (57.7% vs 55.2%, P < 0.001) and gunshot wound (28.7% vs 23.3%, P < 0.001), with higher injury severity scores (composite and by body region) except the superficial body region, and less likely to survive to discharge (73.5% vs 96.6%, P < 0.001). Vecuronium (35.4%) and midazolam (27.9%) were the most frequently used paralytic and sedative, respectively. CONCLUSIONS: Patients undergoing airway intervention were most frequently injured by explosive or gunshot wound. Intubations and cricothyrotomies were the most frequent airway interventions performed. Patients undergoing interventions were more critically injured, with higher mortality rates. Further research is needed to determine methods to reduce mortality in this critically injured population.

Rhabdomyolysis among Critically Ill Combat Casualties: Long-Term Outcomes.

BACKGROUND: Although rhabdomyolysis has been associated with acute kidney injury and mortality in the short term, the long-term consequences of an episode of rhabdomyolysis remain unknown. We sought to identify the long-term outcomes of rhabdomyolysis, including mortality, renal function, and incidence of hypertension (HTN), among service members initially admitted to the intensive care unit after sustaining a combat injury in Iraq or Afghanistan between February 1, 2002 and February 1, 2011. METHODS: Information on age, sex, injury severity score, mechanism of injury, serum creatinine, burn injury, presenting mean arterial pressure, and creatine kinase were retrospectively collected and analyzed for 2,208 patients. Standard descriptive tests were used to compare characteristics of patients with and without rhabdomyolysis. Competing risk Cox proportional hazards models were performed to assess the associated risk of rhabdomyolysis with both HTN and poor renal function. RESULTS: While rhabdomyolysis was associated with HTN on univariate analysis (hazard ratio [HR] 1.30, 95% CI 1.03-1.64; p = 0.029), this difference did not persist on multivariable analysis (HR 1.27, 95% CI 0.99-1.62; p = 0.058). The median estimated glomerular filtration rate (eGFR) was 119 (interquartile range [IQR] 103-128) among those with rhabdomyolysis, compared with 108 (IQR 94-121) in the group without rhabdomyolysis (p < 0.001). CONCLUSION: After adjustment, patients with rhabdomyolysis were not at an increased risk of HTN compared to patients without rhabdomyolysis. eGFR was paradoxically higher in patients with rhabdomyolysis. There was no association found between rhabdomyolysis and mortality.

Usefulness of routine computed tomography in the evaluation of penetrating war injuries to the chest.

OBJECTIVES: This review was conducted to compare the contributions of chest X-ray (CXR) and computed tomography (CT) towards detecting intrathoracic damage in patients with penetrating war injuries to the chest and to determine whether identification of additional injuries by chest CT will have an impact on the choice of therapeutic interventions and clinical outcomes. METHODS: We reviewed records of 449 patients (374 men, mean age 29.3 ± 14.8 years) who were admitted to our hospital with penetrating war injuries to the chest over a 7-year period. Collected data included mechanisms of injury, associated injuries, results of CXRs and chest CTs, methods of management, in-hospital stays, complications and mortalities. RESULTS: Immediate screening CXRs were obtained in all patients not requiring emergent thoracotomies, of which 91.4% showed positive signs of injury. Chest CTs were performed at the discretion of the physicians in 49.4% of patients, and CXR-positive findings were confirmed in all cases, while revealing additional injuries in 11% of patients. Chest CT findings led to additional closed chest drainage in 5.6% of patients but had no impact on treatment strategy in 94.4% of scanned patients. Follow-up CXRs showed new positive findings in 22 patients, leading to additional closed chest drainage in 3 patients and delayed open thoracotomies in 7 other patients. CONCLUSIONS: CXRs continue as the primary diagnostic modality in the assessment of patients with penetrating war injuries to the chest. Chest CTs can be omitted in most patients, thus reducing CT imaging case-load substantially, while most clinically significant chest injuries remain sufficiently recognized.

Integrating Chemical Biological, Radiologic, and Nuclear (CBRN) Protocols Into TCCC Introduction of a Conceptual Model - TCCC + CBRN = (MARCHE)2.

The authors would like to introduce TCCC [Tactical Combat Casualty Care] + CBRN [chemical, biological, radiological, and nuclear] = (MARCHE)2 as a conceptual model to frame the response to CBRN events. This model is not intended to replace existing and well-established literature on CBRNE events but rather to serve as a response tool that is an adjunct to agent specific resources.

Assessment of prehospital hemorrhage and airway care using a simulation model.

BACKGROUND: The quality of prehospital care impacts patient outcomes. Military efforts have focused on training revision and the creation of high-fidelity simulation models to address potentially survivable injuries. We sought to investigate the applicability of models emphasizing hemorrhage control and airway management to a civilian population. METHODS: Prehospital health care providers (PHPs) undergoing their annual training were enrolled. A trauma scenario was simulated with two modules: hemorrhage control and airway management. Experienced raters used a validated tool to assess performance. Pearson correlation, logistic regression, and χ tests were used for analysis. RESULTS: Ninety-five PHPs participated with a mean experience of 15.9 ± 8.3 years, and 7.4% reported past military training. The PHPs' overall execution rate of the six hemorrhage control measures varied from 38.9% to 88.4%. The median blood loss was 1,700 mL (interquartile range, 1,043-2,000), and the mean global rater score was 25.0 ± 7.4 (scale, 5-40). There was a significant relationship between PHP profession and past military experience to their consideration of blood transfusion and tranexamic acid. An inverse relationship between blood loss and global rater score was found (r = -0.59, n = 88, p = 1.93 × 10). After simulated direct laryngoscope failure in the airway module, 58% of PHPs selected video laryngoscopy over placement of a supraglottic airway. Eighty-six percent of participants achieved bilateral chest rise in the manikin regardless of management method. Participants reported improved comfort with skills after simulation. CONCLUSION: Our data reveal marginal performance in hemorrhage control regardless of the PHP's prior experience. The majority of PHPs were able to secure an advanced airway if direct laryngoscope was unavailable with a predisposition for video laryngoscopy over supraglottic airway. Our findings support the need for continued training for PHPs highlighting hemorrhage control maneuvers and increased familiarity with airway management options. Improved participant confidence posttraining gives credence to simulation training. LEVEL OF EVIDENCE: Prognostic/epidemiological study, level III.

Tele-Pediatric Intensive Care for Critically Ill Children in Syria.

BACKGROUND: Armed conflicts can result in humanitarian crises and have major impacts on civilians, of whom children represent a significant proportion. Usual pediatric medical care is often disrupted and trauma resulting from war-related injuries is often devastating. High pediatric mortality rates are thus experienced in these ravaged medical environments. INTRODUCTION: Using simple communication technology to provide real-time management recommendations from highly trained pediatric personnel can provide substantive clinical support and have a significant impact on pediatric morbidity and mortality. MATERIALS AND METHODS: We implemented a "Tele-Pediatric Intensive Care" program (Tele-PICU) to provide real-time management consultation for critically ill and injured pediatric patients in Syria with intensive care needs. RESULTS: Over the course of 7 months, 19 cases were evaluated, ranging in age from 1 day to 11 years. Consultation questions addressed a wide range of critical care needs. Five patients are known to have survived, three were transferred, five died, and six outcomes were unknown. DISCUSSION: Based on this limited undertaking with its positive impact on survival, further development of Tele-PICU-based efforts with attention to implementation and barriers identified through this program is desirable. CONCLUSION: Even limited Tele-PICU can provide timely and potentially lifesaving assistance to pediatric care providers. Future efforts are encouraged.