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2.
J R Army Med Corps ; 165(5): 338-341, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31129648

RESUMO

INTRODUCTION: The extent of the French forces' territory in the Sahel band generates long medical evacuations. In case of many victims, to respect the golden hour rule, first-line sorting is essential. Through simulation situations, the aim of our study was to assess whether the use of ultrasound was useful to military doctors. METHODS: In combat-like exercise conditions, we provided trainees with a pocket-size ultrasound. Every patient for whom the trainees chose to perform ultrasound in role 1 was included. An extended focused assessment with sonography for trauma (E-FAST) was performed with six basic sonographic views. We evaluated whether these reference views were obtained or not. Once obtained by the trainees, pathological views corresponding to the scenario were shown to assess whether the trainees modified their therapeutic management strategy and their priorities. RESULTS: 168 patients were treated by 15 different trainee doctors. Of these 168 patients, ultrasound (E-FAST or point-of-care ultrasound) was performed on 44 (26%) of them. In 51% (n=20/39) of the situations, the practitioners considered that the realisation of ultrasound had a significant impact in terms of therapeutic and evacuation priorities. More specifically, it changed therapeutic decisions in 67% of time (n=26/39) and evacuation priorities in 72% of time (n=28/39). CONCLUSION: This original work showed that ultrasound on the battlefield was possible and useful. To confirm these results, ultrasound needs to be democratised and assessed in a real operational environment.


Assuntos
Medicina Militar/métodos , Modelos Teóricos , Conflitos Armados , Estudos de Viabilidade , /estatística & dados numéricos , Humanos , Militares/educação , Tempo para o Tratamento , Transporte de Pacientes
3.
Int J Law Psychiatry ; 64: 34-39, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31122638

RESUMO

Even though the Bush Administration opened the Guantánamo Bay detention facility in 2002 in response to the September 11, 2001 attacks in the United States, little remains known about how forensic mental health evaluations relate to the process of detainees who are charged before military commissions. This article discusses the laws governing Guantánamo's military commissions system and mental health evaluations. Notably, the US government initially treated detainees as "unlawful enemy combatants" who were not protected under the US Constitution and the United Nations Convention Against Torture and Other Forms of Cruel, Inhuman or Degrading Treatment, allowing for the use of "enhanced interrogation techniques." In subsequent legal documents, however, the US government has excluded evidence obtained through torture, as defined by the US Constitution and the United Nations Convention Against Torture. Using open-source document analysis, this article describes the reasons and outcomes of all forensic mental health evaluations from Guantánamo's opening to 2018. Only thirty of 779 detainees (~3.85%) have ever had charges referred against them to the military commissions, and only nine detainees (~1.16%) have ever received forensic mental health evaluations pertaining to their case. Of these nine detainees, six have alleged mental torture while in US custody. This paper shows that leaders in the United States and Europe should consider whether counterterrorism policies that supersede traditional health and human rights complicate the ability of future governments to prosecute cases when successive leaders change laws, a pertinent consideration as North American and European states grapple with the return of foreign fighters.


Assuntos
Transtornos Mentais/diagnóstico , Prisioneiros/psicologia , Prisões , Adulto , Cuba , Feminino , Psiquiatria Legal/métodos , Humanos , Masculino , Competência Mental/legislação & jurisprudência , Competência Mental/psicologia , Pessoa de Meia-Idade , Medicina Militar/métodos , Prisioneiros/estatística & dados numéricos , Terrorismo/legislação & jurisprudência , Terrorismo/psicologia , Tortura/psicologia , Estados Unidos , Adulto Jovem
5.
Medicine (Baltimore) ; 98(18): e15406, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31045795

RESUMO

BACKGROUND: Traumatic vascular injury is caused by explosions and projectiles (bullets and shrapnel); it may affect the arteries and veins of the limbs, and is common in wartime, triggering bleeding, and ischemia. The increasing use of high-energy weapons in modern warfare is associated with severe vascular injuries. METHODS: To summarize the current evidence of diagnosis and treatment for traumatic vascular injury of limbs, for saving limbs and lives, and put forward some new insights, we comprehensively consulted literatures and analyzed progress in injury diagnosis and wound treatment, summarized the advanced treatments now available, especially in wartime, and explored the principal factors in play in an effort to optimize clinical outcomes. RESULTS: Extremity vascular trauma poses several difficult dilemmas in diagnosis and treatment. The increasing use of high-energy weapons in modern warfare is associated with severe vascular injuries. Any delay in treatment may lead to loss of limbs or death. The development of diagnose and treat vascular injury of extremities are the clinical significance to the tip of military medicine, such as the use of fast, cheap, low invasive diagnostic methods, repairing severe vascular injury as soon as possible, using related technologies actively (fasciotomy, etc). CONCLUSION: We point out the frontier of the diagnosis and treatment of traumatic vascular injury, also with a new model of wartime injury treatment in American (forward surgical teams and combat support hospitals), French military surgeons regarding management of war-related vascular wounds and Chinese military ("3 districts and 7 grades" model). Many issues remain to be resolved by further experience and investigation.


Assuntos
Medicina de Emergência/métodos , Extremidades , Medicina Militar/métodos , Lesões do Sistema Vascular/diagnóstico , Lesões do Sistema Vascular/terapia , Amputação/métodos , Índice Tornozelo-Braço , Traumatismos por Explosões/diagnóstico , Traumatismos por Explosões/terapia , Prótese Vascular , Descompressão Cirúrgica/métodos , Fasciotomia/métodos , Fraturas Ósseas/terapia , Humanos , Militares , Estudos Retrospectivos , Transplante de Pele/métodos , Fatores de Tempo , Índices de Gravidade do Trauma , Estados Unidos , Procedimentos Cirúrgicos Vasculares/métodos , Lesões do Sistema Vascular/diagnóstico por imagem
6.
Transfusion ; 59(S2): 1587-1592, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30980738

RESUMO

Recent studies have demonstrated that early transfusion of plasma or RBCs improves survival in patients with severe trauma and hemorrhagic shock. Time to initiate transfusion is the critical factor. It is essential that transfusion begin in the prehospital environment when transport times are longer than approximately 15 to 20 minutes. Unfortunately, logistic constraints severely limit the use of blood products in the prehospital setting, especially in military, remote civilian, and mass disaster circumstances, where the need can be most acute. US military requirements for logistically supportable blood products are projected to increase dramatically in future conflicts. Although dried plasma products have been available and safely used in a number of countries for over 20 years, there is no dried plasma product commercially available in the United States. A US Food and Drug Administration-approved dried plasma is urgently needed. Considering the US military, disaster preparedness, and remote civilian trauma perspectives, this is an urgent national health care issue.


Assuntos
Transfusão de Componentes Sanguíneos/métodos , Medicina de Desastres/métodos , Medicina Militar/métodos , Plasma , Choque Hemorrágico/terapia , Aprovação de Drogas , Humanos , Estados Unidos , United States Food and Drug Administration
7.
Transfusion ; 59(S2): 1446-1452, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30980744

RESUMO

The shift toward using a transfusion strategy in a ratio to mimic whole blood (WB) functionality has revitalized WB as a viable option to replace severe blood loss in civilian health care. A military-civilian collaboration has contributed to the reintroduction of WB at Haukeland University Hospital in Bergen, Norway. WB has logistical and hemostatic advantages in both the pre- and in-hospital settings where the goal is a perfectly timed balanced transfusion strategy. In this paper, we describe an event leading to activation of our emergency WB collection strategy for the first time. We evaluate the feasibility of our civilian walking blood bank (WBB) to cover the need of a massive amount of blood in an emergency situation. The challenges are discussed in relation to the different stages of the event with the recommendations for improvement in practice. We conclude that the use of pre-screened donors as a WBB in a civilian setting is feasible. The WBB can provide platelet containing blood components for balanced blood resuscitation in a clinically relevant time frame.


Assuntos
Bancos de Sangue , Doadores de Sangue , Segurança do Sangue , Seleção do Doador , Hospitais Militares , Medicina Militar , Bancos de Sangue/organização & administração , Bancos de Sangue/normas , Segurança do Sangue/métodos , Segurança do Sangue/normas , Seleção do Doador/organização & administração , Seleção do Doador/normas , Feminino , Hospitais Militares/organização & administração , Hospitais Militares/normas , Humanos , Masculino , Medicina Militar/métodos , Medicina Militar/organização & administração , Medicina Militar/normas , Noruega
8.
Transfusion ; 59(S2): 1608-1611, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30980745

RESUMO

Aerial drone technology is now in use to improve medical care, especially blood delivery. The use of aerial drones is broader than just this and includes aerial photography, express shipping and delivery, disaster management, search and rescue operations, crop monitoring, weather tracking, law enforcement, and structural assessment. This wide use promises to accelerate and, ideally, reduce the cost of technological advances of drones. By doing so, drone use offers the opportunity of improving health care, particularly in remote and/or underserved environments by decreasing lab testing turnaround times, enabling just-in-time lifesaving medical supply/device delivery, and reducing costs of routine prescription care in rural areas.


Assuntos
Aeronaves , Transfusão de Sangue , Assistência à Saúde/métodos , Medicina de Desastres , Medicina Militar , Transfusão de Sangue/instrumentação , Transfusão de Sangue/métodos , Medicina de Desastres/instrumentação , Medicina de Desastres/métodos , Humanos , Medicina Militar/instrumentação , Medicina Militar/métodos
9.
Transfusion ; 59(S2): 1453-1458, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30980750

RESUMO

BACKGROUND: Hemorrhage is the leading cause of death on the battlefield. Damage control resuscitation guidelines in the US military recommend whole blood as the preferred resuscitation product. The Armed Services Blood Program (ASBP) has initiated low-titer group O whole blood (LTOWB) production and predeployment donor screening to make whole blood more available to military forces. STUDY DESIGN AND METHODS: ASBP donor centers updated procedures and labeling for LTOWB production. Donors are screened according to US Food and Drug Administration regulations and standard operating procedures. Group O donors are tested for anti-A and anti-B titer levels. Additionally, military personnel notified for pending deployment coordinate with their local ASBP donor center to complete whole blood donor prescreening. The process consists of completing a donor history questionnaire, processing of blood samples for blood group and infectious disease testing, and titer determination for group O personnel. RESULTS: Since March 2016, 7940 LTOWB units have been manufactured at ASBP donor centers and shipped in support of combat operations. Additionally, ASBP donor centers have screened several thousand service members before deployment. From these screenings, the donor low titer rate was 68% and infectious disease reactive test rate was extremely low (≤0.004). CONCLUSION: Whole blood is now the preferred blood product for resuscitation of combat trauma patients. The ASBP partnered with combat forces to screen personnel before deployment. Additionally, LTOWB is manufactured and shipped in support of combat operations. These efforts are expanding the availability of LTOWB for the warfighter.


Assuntos
Sistema ABO de Grupos Sanguíneos , Doadores de Sangue , Transfusão de Sangue/métodos , Medicina Militar , Militares , Ressuscitação/métodos , Bancos de Sangue/organização & administração , Bancos de Sangue/normas , Seleção do Doador/métodos , Seleção do Doador/organização & administração , Seleção do Doador/normas , Feminino , Humanos , Masculino , Medicina Militar/métodos , Medicina Militar/organização & administração , Medicina Militar/normas , Estados Unidos
10.
Transfusion ; 59(S2): 1459-1466, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30980759

RESUMO

BACKGROUND: French military operations in the Sahel conducted since 2013 over more than 5 million square kilometers have challenged the French Military Health Service with specific problems in prolonged field care. STUDY DESIGN AND METHODS: To describe these challenges, we retrospectively analyzed the prehospital data from the first 5 years of these operations within a delimited area. RESULTS: One hundred eighty-three servicemen of different nationalities were evacuated, mainly as a result of explosions (73.2%) or gunshots (21.9%). Their mean number evacuation was 2.2 (minimum, 1; maximum, 8) per medical evacuation with a direct evacuation from the field to a Role 2 medical treatment facility (MTF) for 62% of them. For the highest-priority casualties (N = 46), the median time [interquartile range] from injury to a Role 2 MTF was 130 minutes [70 minutes to 252 minutes], exceeding 120 minutes in 57% of cases and 240 minutes in 26%. The most frequent out-of-hospital medical interventions were external hemostasis, airway and hemopneumothorax management, hypotensive resuscitation, analgesia, immobilization, and antibiotic administration. Prehospital transfusion (RBCs and/or lyophilized plasma) was started three times in the field, two times during helicopter medical evacuation, and five times in tactical fixed wing medical aircraft. Lyophilized plasma was confirmed to be particularly suitable in these settings. One of the specific issues involved in lengthy prehospital time was the importance to reassess and convert tourniquets prior to Role 2 MTF admission. CONCLUSION: Main challenges identified include reducing evacuation times as much as possible, preserving ground deployment of sufficiently trained medics and medical teams, optimization of transfusion strategies, and strengthening specific prolonged field care equipment and training.


Assuntos
Transfusão de Sangue , Serviços Médicos de Emergência , Medicina Militar , Militares , Ressuscitação , Ferimentos e Lesões/terapia , Adulto , Resgate Aéreo , Transfusão de Sangue/métodos , Transfusão de Sangue/normas , Serviços Médicos de Emergência/métodos , Serviços Médicos de Emergência/organização & administração , Serviços Médicos de Emergência/normas , Feminino , França , Humanos , Masculino , Medicina Militar/métodos , Medicina Militar/organização & administração , Medicina Militar/normas , Ressuscitação/métodos , Ressuscitação/normas , Ferimentos e Lesões/mortalidade
11.
J Trauma Acute Care Surg ; 87(1): 68-75, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30985476

RESUMO

BACKGROUND: Adenosine, lidocaine, and magnesium (ALM) is a cardioplegic agent shown to improve survival by improving cardiac function, tissue perfusion, and coagulopathy in animal models of shock. We hypothesized prehospital ALM treatment in hemorrhagic shock would improve survival compared to current Tactical Combat Casualty Care (TCCC) resuscitation beyond the golden hour. METHODS: Swine were randomized to: (1) TCCC, (2) 2 mL·kg vehicle control (VC), (3) 2 mL·kg ALM + drip, (4) 4 mL·kg ALM + drip, 5) 4 mL·kg ALM + delayed drip at 0.5 mL·kg·h, 6) 4 mL/kg VC, 7) 4 mL·kg ALM for 15 minutes + delayed drip at 3 mL·kg·h. Animals underwent pressure controlled hemorrhage to mean arterial pressure (MAP) of 30 mm Hg (S = 0). Treatment was administered at T = 0. After 120 minutes of simulated prehospital care (T = 120) blood product resuscitation commenced. Physiologic variables were recorded and laboratories were drawn at specified time points. RESULTS: Tactical Combat Casualty Care demonstrated superior survival to all other agents. The VC and ALM groups had lower MAPs and systolic blood pressures compared with TCCC. Except for the VC groups, lactate levels remained similar with correction of base deficit after prehospital resuscitation in all groups. Kidney function and liver function remained comparable across all groups. Compared with baseline values, TCCC demonstrated significant hypocoagulability. CONCLUSION: Adenosine, lidocaine, and magnesium, as administered in this study, are inferior to current Hextend-based resuscitation for survival from prolonged hemorrhagic shock in this model. In survivors, ALM groups had lower systolic blood pressures and MAPs, but provided a protective effect on coagulopathy as compared to TCCC. Adenosine, lidocaine, and magnesium do not appear to be a suitable low volume replacement to current TCCC resuscitation. The reduced coagulopathy compared to TCCC warrants future studies of ALM, perhaps as a therapeutic adjunct.


Assuntos
Adenosina/uso terapêutico , Soluções Cardioplégicas/uso terapêutico , Serviços Médicos de Emergência/métodos , Lidocaína/uso terapêutico , Magnésio/uso terapêutico , Medicina Militar/métodos , Ressuscitação/métodos , Choque Hemorrágico/terapia , Ferimentos e Lesões/terapia , Adenosina/administração & dosagem , Animais , Soluções Cardioplégicas/administração & dosagem , Modelos Animais de Doenças , Lidocaína/administração & dosagem , Magnésio/administração & dosagem , Masculino , Ressuscitação/mortalidade , Choque Hemorrágico/mortalidade , Suínos , Ferimentos e Lesões/mortalidade
12.
Injury ; 50(5): 1133-1137, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30851979

RESUMO

INTRODUCTION: The military operations carried out by the French armed forces, occasionally require the use of the Surgical Life-saving Module (SLM), to ensure the surgical support of its soldiers. Due to its extreme mobility and capacity of fast deployment, SLM is particularly useful in small-scale military operations, such as Special Forces missions. In 2017, the French SLM was for the first time used to ensure surgical support of allied forces, which were lacking forward surgical capabilities. MATERIALS AND METHODS: the SLM is a mobile, heliborne, airborne, surgical structure with parachuting capability onto land or sea, therefore essentially focused on life-saving procedures, also known as "damage control" surgery. Due to the need for mobility and rapid implementation, the SLM is limited to a maximum of 5 interventions or, in terms of injuries, to 1 or 2 seriously injured patients. RESULTS: Over a period of 2 months, 5 medical teams were successively deployed with the SLM. A total of 157 casualties were treated. The most common injuries were caused by shrapnel 561%), followed by firearms (36%), and blunt trauma (2.5%). Injuries included the limbs (56%), thorax (18%), abdomen (13%), head (11%), and neck (2%). The average ISS was 8.5 (1-25) with 26 patients presenting with an ISS greater than or equal to 15. The average NISS was 10.8 (1-75) with 34 casualties having an NISS equal to or greater than 15. The surgical procedures were broken down as follows: 126 dressings, 16 laparotomies, 7 thoracotomies, 12 isolated thoracic drains (without thoracotomy), 1 cervicotomy, 12 amputations, 7 limb splints, 2 limb fasciotomies, 2 external fixators and 1 femoral fracture traction. CONCLUSIONS: The numerous SLM deployments in larger operations highlighted its ability to adapt both in terms of equipment and personnel. Continuous management of equipment logistics, robust personnel training, and appropriate organization of the evacuation procedures, were the key elements for optimizing combat casualty care. As a consequence, the SLM appears to be an operational surgical unit of choice during deployments.


Assuntos
Medicina Militar , Militares , Traumatismo Múltiplo/cirurgia , Lesões Relacionadas à Guerra/cirurgia , Adulto , Feminino , Guias como Assunto , Humanos , Masculino , Medicina Militar/métodos , Estudos Retrospectivos
13.
Mil Med ; 184(Suppl 1): 133-137, 2019 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-30901391

RESUMO

OBJECTIVE: Care provided to a casualty in the prehospital combat setting can influence subsequent medical interactions and impact patient outcomes; therefore, we aimed to describe the incidence of specific prehospital interventions (lifesaving interventions (LSIs)) performed during the resuscitation and transport of combat casualties. METHODS: We performed a prospective observational, IRB approved study between November 2009 and March 2014. Casualties were enrolled as they were cared for at nine U.S. military medical facilities in Afghanistan. Data were collected using a standardized collection form. Determination if a prehospital intervention was performed correctly, performed incorrectly, or was necessary but was not performed (missed LSIs) was made by the receiving facility's medical provider. RESULTS: Two thousand one hundred and six patients met inclusion criteria. The mean age was 25 years and 98% were male. The most common mechanism of injury was explosion 57%. There were 236 airway interventions attempted, 183 chest procedures, 1,673 hemorrhage control, 1,698 vascular access, and 1,066 hypothermia preventions implemented. There were 142 incorrectly performed interventions and 360 were missed. CONCLUSIONS: In our study, the most commonly performed prehospital LSI in a combat setting were for vascular access and hemorrhage control. The most common incorrectly performed and missed interventions were airway interventions and chest procedures respectively.


Assuntos
Serviços Médicos de Emergência/métodos , Adolescente , Adulto , Campanha Afegã de 2001- , Afeganistão , Manuseio das Vias Aéreas/métodos , Manuseio das Vias Aéreas/estatística & dados numéricos , Cateterismo Periférico/métodos , Cateterismo Periférico/estatística & dados numéricos , Serviços Médicos de Emergência/estatística & dados numéricos , Feminino , Humanos , Hipotermia/terapia , Masculino , Medicina Militar/métodos , Medicina Militar/estatística & dados numéricos , Estudos Prospectivos
14.
Mil Med ; 184(Suppl 1): 102-105, 2019 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-30901422

RESUMO

Historically, meningococcal disease has had a devastating impact on U.S. military personnel, but since the introduction of a vaccine in the 1970s, rates have dropped over 90%.1 Department of Defense instructions mandate a meningococcal vaccine for all service personnel. In the last 5 years, rates of meningococcal disease in the military are similar to the U.S. general population. The active duty incidence was 0.21 cases per 100,000 person-years from 2013-2017. Six cases occurred in the 6 months between September 2016 and February 2017; of these, only one was determined to be a vaccine-covered strain. Ongoing surveillance shows vaccination has resulted in a dramatic reduction in meningococcal cases in the military; however, it also demonstrates cases continue to occur sporadically. The recent emergence of new cases reminds us that surveillance and accompanying research are important for evaluating changes in the disease and informing new vaccine development and policy.


Assuntos
Infecções Meningocócicas/diagnóstico , Vigilância da População/métodos , Adolescente , Adulto , Humanos , Incidência , Infecções Meningocócicas/epidemiologia , Vacinas Meningocócicas/uso terapêutico , Medicina Militar/métodos , Sorotipagem/métodos
15.
Mil Med ; 184(Suppl 1): 361-366, 2019 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-30901457

RESUMO

BACKGROUND: Current military recommendations include the use of tourniquets (TQ) in appropriate pediatric trauma patients. Although the utility of TQs has been well documented in adult patients, the efficacy of TQ application in pediatric patients is less clear. The current study attempted to identify physical constraints for TQ use in two simulated pediatric limb models. METHODS: Five different TQ (Combat Application Tourniquet (CAT) Generation 6 and Generation 7, SOFTT (SOF Tactical Tourniquet), SOFTT-W (SOF Tactical Tourniquet - Wide), SWAT-T (Stretch Wrap and Tuck - Tourniquet) and a trauma dressing were evaluated in two simulated pediatric limb models. Model one employed four cardiopulmonary resuscitation (CPR) manikins simulating infant (Simulaids SaniBaby), 1 year (Gaumard HAL S3004), and 5 years (Laerdal Resusci Junior, Gaumard HAL S3005). Model two utilized polyvinyl chloride (PVC) piping with circumferences ranging from 4.25" to 16.5". Specific end-points included tightness of the TQ and ability to secure the windlass (where applicable). RESULTS: In both models, the ability to successfully apply and secure the TQ depended upon the simulated limb circumference. In the 1-year-old CPR manikin, all windlass TQs failed to tighten on the upper extremity, while all TQs successfully tightened at the high leg and mid-thigh. With the exception of the CAT7 and the SOFTT-W at the mid-thigh, no windlass TQ was successfully tightened at any extremity location on the infant. The SWAT-T was successfully tightened over all sites of all CPR manikins except the infant. No windlass TQ was able to tighten on PVC pipe 5.75" circumference or smaller (age < 24 months upper extremity). All windlass TQs were tightened and secured on the 13.25" and 15.5" circumference PVC pipes (age 7-12 years lower extremity, age >13 years upper extremity). The SWAT-T was tightened on all PVC pipes. DISCUSSION: The current study suggests that commercial windlass TQs can be applied to upper and lower extremities of children aged 5 years and older at the 50%th percentile for limb circumference. In younger children, windlass TQ efficacy is variable. Further study is required to better understand the limitations of TQs in the youngest children, and to determine actual hemorrhage control efficacy.


Assuntos
Antropometria/métodos , Extremidades/patologia , Torniquetes/normas , Pré-Escolar , Desenho de Equipamento/normas , Hemorragia/prevenção & controle , Hemorragia/terapia , Humanos , Lactente , Medicina Militar/métodos , Medicina Militar/normas , Pediatria/instrumentação , Pediatria/métodos , Autoeficácia , Torniquetes/tendências
16.
Mil Med ; 184(Suppl 1): 374-378, 2019 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-30901466

RESUMO

A recent study of all mounted vehicle underbody blast attacks found that 21% of Abbreviated Injury Scale Severity 2+ injuries in the Joint Trauma Analysis and Prevention of Injury in Combat network were injuries to the leg and ankle. To develop effective countermeasure systems for these attacks, the epidemiology and mechanisms of injury from this loading environment need to be quantified. The goal of this study was to develop a military correlate of an existing civilian case review framework, the Crash Injury Research and Engineering Network (CIREN), to consider the differences in military event types and the amount of available vehicle/attack information. Additional data fields were added to the CIREN process to cover military-specific data and "certainty" definitions in the proposed injury hypothesis were modified. To date, six group reviews have been conducted analyzing 253 injuries to the foot/ankle, tibia, femur, pelvis, and lumbar spine from 52 occupants. The familiar format and unclassified nature of the presentations allowed for the involvement of biomechanics experts from multiple disciplines.


Assuntos
Traumatismos por Explosões/classificação , Militares/estatística & dados numéricos , Terrorismo/estatística & dados numéricos , Guerra/estatística & dados numéricos , Campanha Afegã de 2001- , Traumatismos por Explosões/epidemiologia , Humanos , Escala de Gravidade do Ferimento , Guerra do Iraque 2003-2011 , Medicina Militar/métodos , Medicina Militar/tendências , Estados Unidos/epidemiologia
17.
J Trauma Acute Care Surg ; 87(1): 125-129, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30908452

RESUMO

BACKGROUND: Tranexamic acid (TXA) has been shown to decrease mortality and blood product requirements in severely injured patients. Tranexamic acid has also been hypothesized to prevent secondary brain injury in patients with traumatic brain injury. While prior studies have demonstrated improved neurologic outcomes associated with TXA administration in severely injured pediatric patients, no such studies have been performed in adults. METHODS: A retrospective review of all adult trauma admissions to North Atlantic Treaty Organization hospitals in Iraq and Afghanistan between 2008 and 2015. Univariate and multivariate analysis was used to identify factors associated with TXA administration. Patients without a documented head Abbreviated Injury Scale (AIS) were excluded. Patients were propensity matched based on demographics, mechanism of injury, Injury Severity Score (AIS/ISS), presenting Glasgow Coma Scale (GCS) score, initial vitals/laboratory values, and initial transfusion requirement. Primary outcomes were in-hospital mortality and neurologic outcomes measured by discharge GCS scores. Secondary outcomes were respiratory failure and rates of thromboembolic events. RESULTS: Four thousand four hundred seventy-six injured patients 18 years or older were evaluated. Two hundred sixty-five (5.9%) of these patients required a massive transfusion in the first 24 hours, and 174 (3.9%) received TXA. The TXA patients had significantly higher ISS, more penetrating injuries, lower presenting GCS, higher incidence of severe head injury (AIS > 3), and higher transfusion requirements. Ninety-two patients were included in the propensity matched cohort. Of these, patients who received TXA had significantly lower mortality rate (0% vs. 10.1%, p = 0.02) and improvement of GCS score to 14 to 15, irrespective of admission GCS compared with patients who did not receive TXA (100% vs. 87%, p = 0.01). There were no significant differences in number of thromboembolic events recorded between the two groups. CONCLUSION: The TXA administration in adult combat trauma patients was independently associated with decreased mortality and improved neurologic outcomes, with no increase in thromboembolic events. Further study of the possible mechanisms and effect of TXA on brain injury and neurologic outcomes is warranted. LEVEL OF EVIDENCE: Therapeutic, level IV.


Assuntos
Antifibrinolíticos/uso terapêutico , Traumatismos Craniocerebrais/tratamento farmacológico , Ácido Tranexâmico/uso terapêutico , Escala Resumida de Ferimentos , Adulto , Campanha Afegã de 2001- , Transfusão de Sangue , Estudos de Casos e Controles , Traumatismos Craniocerebrais/mortalidade , Traumatismos Craniocerebrais/terapia , Feminino , Escala de Coma de Glasgow , Humanos , Guerra do Iraque 2003-2011 , Masculino , Medicina Militar/métodos , Medicina Militar/estatística & dados numéricos , Estudos Retrospectivos , Resultado do Tratamento , Estados Unidos , Adulto Jovem
18.
BMC Musculoskelet Disord ; 20(1): 126, 2019 Mar 25.
Artigo em Inglês | MEDLINE | ID: mdl-30909910

RESUMO

BACKGROUND: Bone stress fractures are overuse injuries commonly encountered in sports and military medicine. Some fatigue fractures lead to morbidity and loss of active, physically-demanding training days. We evaluated the incidence, anatomical location, risk factors, and preventive measures for fatigue fractures in young Finnish male conscripts. METHODS: Five cohorts of 1000 men performing military service, classified according to birth year (1969, 1974, 1979, 1984, 1989), were analysed. Each conscript was followed for his full military service period (180 days for conscripts with rank and file duties, 270 days for those with special training, 362 days for officers and highly trained conscripts). Data, including physical activity level, were collected from a standard pre-information questionnaire and from the garrisons' healthcare centre medical reports. Risk factor analysis included the conscripts' service class (A, B), length of military service, age, height, weight, body mass index, smoking, education, previous diseases, injuries, and subjective symptoms, as well as self-reports of physical activity before entering the service using a standard military questionnaire. RESULTS: Fatigue fractures occurred in 44 (1.1%) of 4029 men, with an incidence of 1.27 (95% confidence interval: 0.92-1.70) per 1000 follow-up months, and mostly (33/44, 75%) occurred at the tibial shaft or metatarsals. Three patients experienced two simultaneous stress fractures in different bones. Most fatigue fractures occurred in the first 3 months of military service. Conscripts with fatigue fractures lost a total of 1359 (range 10-77) active military training days due to exemptions from duty. Conscripts reporting regular (> 2 times/week) physical activity before entering the military had significantly fewer (p = 0.017) fatigue fractures. Regular physical activity before entering the service was the only strong explanatory, protective factor in the model [IRR = 0.41 (95% CI: 0.20 to 0.85)]. The other measured parameters did not contribute significantly to the incidence of stress fractures. CONCLUSION: Regular and recurrent high-intensity physical activity before entering military service seems to be an important preventive measure against developing fatigue fractures. Fatigue fractures should be considered in conscripts seeking medical advice for complaints of musculoskeletal pain, and taken into consideration in planning military and other physical training programs.


Assuntos
Exercício Físico/fisiologia , Fraturas de Estresse/epidemiologia , Fraturas de Estresse/prevenção & controle , Medicina Militar/métodos , Militares , Adolescente , Adulto , Estudos de Coortes , Finlândia/epidemiologia , Seguimentos , Fraturas de Estresse/diagnóstico , Humanos , Masculino , Distribuição Aleatória , Adulto Jovem
19.
J Emerg Med ; 56(5): 491-498, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30904380

RESUMO

BACKGROUND: Blood products are a cornerstone of trauma resuscitation. From the historically distant battlefields of World War II through present-day conflict around the globe, whole blood (WB) has been a potent tool in the treatment of massive hemorrhagic shock. Component therapy with a targeted ratio of packed red blood cells, platelets, and plasma has previously been utilized. OBJECTIVES: This narrative review describes modern-day WB transfusion, its benefits, potential drawbacks, and implementation. DISCUSSION: The current form of stored low-titer O WB seems to be the safest and most effective solution. There are many advantages to WB, including the maintenance of coagulation factors, the lack of subsequent thrombocytopenia, and the reduction of infused anticoagulant. Several studies suggest its utility in trauma. Most of the disadvantages of WB stem from a lack of prospective data on the topic, which are likely forthcoming. Logistical issues likely present the greatest barrier to this therapy, but an advanced prehospital protocol developed in San Antonio, Texas, has successfully overcome several of these challenges. CONCLUSIONS: Although stored WB holds promise, it is not without its distinct challenges, including logistical issues, which this article addresses. There are programs underway currently that demonstrate its feasibility in metropolitan areas. As demonstrated in military settings, WB is likely the ideal resuscitation fluid for civilian trauma in the prehospital and emergency department settings.


Assuntos
Transfusão de Sangue/métodos , Ferimentos e Lesões/terapia , Transfusão de Sangue/tendências , Hidratação/métodos , Humanos , Medicina Militar/métodos , Medicina Militar/normas , Ressuscitação/métodos , Texas
20.
Curr Opin Anaesthesiol ; 32(2): 227-233, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30817399

RESUMO

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.


Assuntos
Medicina Militar/métodos , Padrões de Prática Médica/normas , Choque Hemorrágico/terapia , Traumatismos Torácicos/terapia , Lesões Relacionadas à Guerra/terapia , Anestesia por Condução/normas , Oclusão com Balão/normas , Transfusão de Sangue/normas , Oxigenação por Membrana Extracorpórea/normas , Humanos , Medicina Militar/normas , Guias de Prática Clínica como Assunto , Ressuscitação/métodos , Ressuscitação/normas , Choque Hemorrágico/diagnóstico , Choque Hemorrágico/etiologia , Traumatismos Torácicos/complicações , Traumatismos Torácicos/diagnóstico , Resultado do Tratamento , Triagem/métodos , Triagem/normas , Lesões Relacionadas à Guerra/complicações , Lesões Relacionadas à Guerra/diagnóstico
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