Feasibility of negative pressure wound therapy during intercontinental aeromedical evacuation of combat casualties.

OBJECTIVE: The objective of this study was to assess the feasibility of utilizing negative pressure wound therapy (NPWT) for the treatment of wartime soft-tissue wounds during intercontinental aeromedical evacuation. BACKGROUND: Attempts to use NPWT during early phases of overseas contingency operations resulted in occasional vacuum system failures and potentially contributed to wound complications. These anecdotal episodes led to a perception that NPWT during aeromedical evacuation carried a high risk of wound complications and limited its use. As a result, NPWT was not frequently applied in the management of soft-tissue wounds before US casualty arrival in the continental United States (CONUS) for wounds sustained in the combat theaters. Concurrently, early NPWT on the traumatic wounds of host nation casualties not requiring aeromedical evacuation seemed to provide many benefits typically associated with the therapy such as decreased infection rates, earlier wound closure, and improved pain management. METHODS: On a daily basis, study investigators reviewed the trauma in-patient census at Landstuhl Regional Medical Center, Germany, to identify patient candidates with soft-tissue extremity or torso wounds that required packing. Patient demographics, injuries, and previous wound treatments were recorded. Surgeons inspected wounds in the operating room and applied a NPWT dressing if deemed appropriate. NPWT was continued throughout the remainder of the patient's hospitalization and also during aeromedical evacuation to CONUS. A study investigator escorted the patient during aeromedical evacuation to educate the flight crews, to record the impact on crew workload, and to troubleshoot the system if necessary. RESULTS: Thirty enrolled patients with 41 separate wounds flew from Germany to CONUS with a portable NPWT system (VAC Freedom System; Kinetic Concepts Incorporated, San Antonio, TX). All 30 patients arrived at the destination facilities with intact and functional systems. No significant in-flight complications were identified, impact on flight crew workload was negligible, and subjective feedback from both flight crews and patients was uniformly positive. For 29 patients, the NPWT dressing was replaced (frequently with serial exchanges) during initial surgical treatment in CONUS; the 30th patient underwent delayed primary closure of his right forearm fasciotomy. Receiving care teams reported no complications attributable to NPWT during aeromedical evacuation. CONCLUSIONS: NPWT is feasible during intercontinental aeromedical evacuation of combat casualties without an increase in wound complications or a significant impact on air crew workload. Further studies are indicated to evaluate the efficacy of NPWT in combat wounds compared with other wound care techniques.

Advances in the care of battlefield orthopaedic injuries.

Musculoskeletal wounds are the most common type of injury among survivors of combat trauma. The treatment of these wounds entails many challenges. Although methods of care are evolving, significant gaps remain as knowledge of civilian trauma is extrapolated to combat injuries. It is important to discuss issues related to the use of portable vacuum-assisted wound closure devices during transport, as well as the prevention of heterotopic ossification and the participation of civilian orthopaedic trauma experts in caring for injured service members through the Distinguished Visiting Scholar Program.

Use of negative pressure wound therapy during aeromedical evacuation of patients with combat-related blast injuries.

The purpose of the study was to evaluate safety and feasibility of negative pressure wound therapy (NPWT) during aeromedical evacuation from a combat zone to a regional treatment center. A retrospective review of patients who received NPWT during aeromedical evacuation from Iraq or Afghanistan to Landstuhl Regional Medical Center (LRMC) was performed. Data were collected describing mechanism of injury; anatomic site of NPWT application; number of sites per patient; date and time of NPWT application; date, time, and wound condition on arrival and inspection at LRMC; and complications encountered during aeromedical evacuation. Broad definitions of complications were employed. Any reported malfunction of NPWT devices or need to reinforce NPWT dressings was abstracted. Presence of tissue under the dressing requiring debridement was defined as a minor complication. Major complications were defined as wound sepsis with systemic manifestations. A total of 218 patients who had received NPWT for 298 wounds (1.37 per patient) during aeromedical evacuation were identified. Most wounds were due to high-energy blast or ballistic mechanisms. Average time from NPWT application to removal was 53 hours (range, 18-133 +/- 22 hours). Complications occurred at 14% of NPWT sites and in 19% of patients receiving NPWT. Most recorded complications were minor (95%). Two patients who arrived at LRMC with fever and evidence of wound sepsis improved rapidly after additional operative debridement. In no case was failure of the NPWT device in flight specifically implicated in the genesis of a recorded complication. In-flight device problems were identified in seven cases. Four of these could not be repaired in flight and were clamped. Complications were not increased in this cohort. Use of NPWT during aeromedical evacuation appears safe and feasible in a large cohort of patients with high-energy injuries. Complications were consistent with severity of injury and not related to failure of NPWT.

Closed intramedullary nailing of femoral shaft fractures in an echelon III facility.

This study was performed to assess the safety of performing intramedullary (IM) nailing in an established echelon III theater hospital. Twenty-two patients (23 fractures) sustained subtrochanteric or diaphyseal femur fractures and presented to the Air Force theater hospital (AFTH) at Balad Air Base, Iraq, for definitive treatment. Sixteen grade IIIA open fractures underwent staged intramedullary nailing. Seven closed fractures were treated with either immediate or staged intramedullary nailing as facility operations tempo dictated. Definitive follow-up was only available for 8 fractures at 2 months and for 5 fractures at 6 months, but no patient was readmitted to any U.S. military hospital in Iraq for treatment of infection or intramedullary nail removal. Although the results are not conclusive, the authors suggest that intramedullary nailing may be performed with acceptable infection risk in an established echelon III facility. Further study will help to establish the efficacy of this treatment approach.

Orthopaedic war injuries: from combat casualty care to definitive treatment: a current review of clinical advances, basic science, and research opportunities.

Musculoskeletal war wounds often involve massive injury to bone and soft tissue that differ markedly in character and extent compared with most injuries seen in civilian practice. These complex injuries have challenged orthopaedic surgeons to the limits of their treatment abilities on the battlefield, during medical evacuation, and in subsequent definitive or reconstructive treatment. Newer methodologies are being used in the treatment of these wounds to prevent so-called second hit complications, decrease complications associated with prolonged medical evacuation, reduce the incidence of infection, and restore optimal function. Basic science advances hold the promise of providing foundations for future treatment options that may improve both bone and soft-tissue healing. Research on the treatment of these often devastating wounds also will have broad applicability to trauma resulting from acts of terrorism or from natural disasters.

Levels of medical care in the global war on terrorism.

Trauma care for military personnel injured in Iraq has become increasingly sophisticated. There are five levels, or echelons, of care, each progressively more advanced. Level I care provides immediate first aid at the front line. Level II care consists of surgical resuscitation provided by highly mobile forward surgical teams that directly support combatant units in the field. Level III care is provided through combat support hospitals--large facilities that take time to become fully operational but offer much more advanced medical, surgical, and trauma care, similar to a civilian trauma center. Level IV care is the first echelon at which definitive surgical management is provided outside the combat zone. Level V care is the final stage of evacuation to one of the major military centers in the United States, where definitive stabilization, reconstruction, or amputation of the injured extremity is performed.

Ketorolac use in the national football league: prevalence, efficacy, and adverse events.

Researchers who surveyed usage patterns, effectiveness, and possible adverse effects of ketorolac tromethamine among National Football League players found some common themes among the 31 teams that responded. Though isolated adverse events were noted, most team healthcare providers felt that ketorolac is effective and safe when the team physician directs its use.

The role of negative pressure wound therapy with reticulated open cell foam in the treatment of war wounds.

The treatment of war wounds poses many unique challenges to all healthcare providers (surgeons, flight medics, nurses, etc.), whether they are located at the far forward trauma hospitals located in or near areas of conflict, at regional hospitals such as Landstuhl Medical Center in Germany, or the larger military hospitals in the United States. These complex wounds often involve massive loss of soft tissue and bone, are contaminated, and are unlike most injuries seen at civilian hospitals. Treatment guidelines, or doctrine, are the result of lessons learned in conflicts over the past few centuries dating back to early 19th century Europe through the Vietnam and recent Persian Gulf war. Advances in surgical and medical treatment have resulted from the complex challenges presented to the war trauma surgeon. More than 1 million patients have been treated for chronic pressure ulcers, abdominal wounds, diabetic ulcers, and acute civilian trauma wounds with negative pressure wound therapy with reticulated open cell foam (NPWT/ROCF) as delivered by V.A.C.(R) Therapy (KCI, San Antonio, TX) for over the past decade. However, the use of NPWT/ROCF for the care of war wounds at battlefield trauma hospitals and/or in the aeromedical evacuation transport system aboard aircraft is a new application of this wound treatment not yet accepted as doctrine. Investigational studies are ongoing to study the safety and efficacy of the treatment of battlefield wounds with NPWT/ROCF both for those national citizens treated at the trauma hospitals in Iraq and Afghanistan and for those wounded American and coalition patients who are transported through the aeromedical transport system to medical centers in the United States.