A National Trauma Care System Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury (2016) / Chapter Skim
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Appendix A: Case Studies
Appendix A: Case Studies
Pages 383-428
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evidence-based improvement process. • Processes by which patient and injury information was collected, stored, reviewed and analyzed by the Joint Trauma System (JTS)
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; • military learning process (data management; description of mili tary clinical performance improvement processes, including clinical guideline development and education and training initiatives; and impact of DoD trauma research investment) ; and • knowledge transfer between the military and civilian sectors re garding best practices and lessons learned.
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In a "scoop-and-run strategy," he was flown to the emergency room of a nearby combat support hospital ("Baghdad ER") , arriving 6 minutes after injury.
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The culture of the military as a whole and of this unit in particular had not yet incorporated practices of tactical combat casualty care (TCCC) , which called for the use of tourniquets.
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, and the Pre-Hospital Trauma Registry (PHTR) now captures data from the point of injury to support performance improvement initiatives.
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Implementation was initially uneven as Special Operations Forces implemented tourniquet use much earlier, more rapidly, and more thoroughly relative to the conventional military services. Knowledge was disseminated via consultant visits in theater, in-theater trauma conferences, JTS and TCCC guidelines, predeployment training sites, e-mail, presentations at military and civilian meetings, and journal publications.
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The foundation for this new paradigm is the body of guidelines issued by the U.S. Military's Committee on Tactical Combat Casualty Care and its civilian counterpart, the Committee on Tactical Emergency Casualty Care.
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1996. Tactical combat casualty care in special operations.
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: Implications for the future of combat casualty care. Journal of Trauma and Acute Care Surgery 73(6 Suppl.
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The right upper extremity had suffered a laceration and soft tissue loss in the axilla and exhibited minimal bleeding. A computed tomography (CT)
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The patient was rapidly FIGURE A-2 The image on the left shows right humerus fracture and axillary soft tissue injury. The image on the right shows left humerus fracture.
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of the right forearm. He was transfused 7 units of red blood cells, 6 units of fresh frozen plasma, and 1 apheresis unit of platelets.
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To mitigate the problem of lost patient data and to assist with performance improvement efforts, patient information is now captured and stored in an electronic medical record (EMR) , the Theater Medical Data Store.
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To provide feedback to downrange providers and correct deficiencies such as incomplete fasciotomy, a weekly Thursday Combat Casualty Care teleconference connecting in-theater MTFs with Landstuhl and U.S. MTFs was established in 2006.
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APPENDIX A 397 FIGURE A-4 Cervical spine clearance documentation sheet.
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Current CPGs relevant to blunt trauma with vascular injury are listed in Box A-2. The compartment syndrome and fasciotomy CPG, which prescribes J OINT TRAUMA SYSTEM CLINICAL PRACTICE GUIDELINES Box A-2 RELEVANT TO BLUNT TRAUMA WITH VASCULAR INJURY • Battle/Non-Battle Injury Documentation Resuscitation Record • Blunt Abdominal Trauma • Cervical Spine Evaluation • Compartment Syndrome and Fasciotomy • Damage Control Resuscitation • Hypothermia Prevention • Infection Control • Intratheater Transfer and Transport • Management of Pain, Anxiety, and Delirium • Management of War Wounds • Prehospital Care (Tactical Combat Casualty Care guidelines)
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The weekly Thursday Combat Casualty Care teleconference, now called the Combat Casualty Care Curriculum, has evolved from a strictly performance improvement focus to an educational forum. Each week a continuing medical education (CME)
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2013. Compartment syndrome performance improvement project is associated with increased combat casualty survival.
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Journal of Trauma and Acute Care Surgery 73(2 Suppl.
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was 15. Initial vital signs were blood pressure 156/67, heart rate 124, respiratory rate 34, saturation 100 percent on supplemental oxygen delivered by nonrebreather mask.
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U.S. and Coalition military patients with severe burns are quickly evacuated out of theater by critical care air transport teams, and patients with the most severe burns are transported by a specialized burn team from the U.S.
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available in Baghdad. This was just one of many cases indicating the need to deploy a set of pediatric equipment and physicians trained in pediatric critical care to combat support hospitals in theater.
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While capabilities to care for these complex pediatric patients generally have improved since the start of the wars, pediatric host national cases are not rigorously analyzed for performance improvement purposes, and there are no published studies on improvement in these patients over time nor is there any pediatric-specific monitoring of CPG compliance. Even when performance improvement processes such as mortality and morbidity reviews were carried out at combat support hospitals, transmission of the resultant lessons learned to the next group of physicians was a challenge.
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, and may have use in a variety of civilian trauma and research centers. Military experience with adult burn patients also has informed burn care in the civilian sector.
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U.S. Combat Casualty Care Research Program (CCCRP)
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with extensive soft tissue injury with debris, fragments, and lower extremity fractures. Bilateral pneumatic tourniquets at the thigh cause loss of vascular opacification.
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Tactical Evacuation During tactical evacuation, intraosseous vascular access was established, and further bleeding control measures were taken (packing and pressure on the perineal wound, and transfusion with 1 unit each of red blood cells and fresh frozen plasma)
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On the day following the injury, the patient was transported by a critical care air transport team to a Role 3 strategic evacuation (STRATEVAC) hub, where washouts of the lower extremity wounds were performed and negative pressure dressings applied, the pelvic external fixator was adjusted, and an end colostomy was fashioned.
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Whole blood and freeze-dried plasma are available only in Special Operations units, and red blood cells and plasma are available only on a limited basis for medical evacuation (MEDEVAC) , not for field care.
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Performance Improvement DoDTR data were analyzed in 2010 in response to concerns from deployed line and medical communities regarding an apparent increase in multiple limb amputations concomitant with severe genitourinary injury. This analysis revealed a clear increase in the frequency of the injury pattern described as DCBI.
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. Trauma leadership at the National Naval Medical Center informed the JTS of these fungal infections, and infectious disease colleagues at Landstuhl Regional Medical Center and the Trauma Infectious Disease Outcomes Study Group at the Uniformed Services University of the Health Sciences undertook the development of the Invasive Fungal Infection in War Wounds CPG.
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To date, DoD's Combat Casualty Care Research Program has yielded several junctional tourniquet models that have been approved by the FDA and fielded on a limited basis. DCBI, which is associated with significant soft tissue injury and hemorrhage leading to the coagulopathy of trauma, also prompted a particular focus on evaluation of the use of TXA, an antifibrinolytic agent, to improve combat trauma mortality, based on the findings of the CRASH-2 (Clinical Randomization of an Antifibrinolytic in Significant Haemorrhage)
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formulary, and a recommendation for its use was C added to the JTS Damage Control Resuscitation CPG in 2011, even though it has not been approved by the FDA for the treatment of hemorrhage.3 Because of continued concerns regarding potential adverse effects of TXA (e.g., thrombo mbolic events) , its use and the associated risk of complica e tions remain closely monitored through JTS performance improvement processes.
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provided strong, high-quality evidence for early, balanced massive transfusion ratios. Military damage control resuscitation practices have since been widely adopted in the civilian sector.
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2015. Prehospital transfusion of plasma and red blood cells in trauma patients.
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2010. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2)
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Hypertonic saline was administered, and he was transfused 2 units of red blood cells en route. He continued to exhibit decorticate posturing.
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He underwent bronchoscopy to evaluate the effects of the surgical airway procedures and was found to have no evidence of tracheal injury. Evacuation Out of Theater The patient was transferred out of theater on post-injury day 1 via the critical care air transport team.
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In flight, cerebral perfusion pressure was maintained at greater than 60 mmHg with low-dose vasopressors, and intracranial pressure was maintained at less than 20 mmHg. The patient was transfused 2 units of red blood cells and a 300-mL bolus of normal saline.
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Numerous calvarial fragments remain. Followng surgery, his intracranial pressure improved, and enteral feeding i and prophylaxis for deep venous thrombosis were initiated.
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In this case, the actions taken by the medic in the field to prevent hypoxia and secondary brain injury, prompt evacuation of the patient to a Role 3 MTF, rapid resuscitation to restore cerebral perfusion and ensure oxygenation, damage control resuscitation, aggressive neurosurgical interventions, and early multidisciplinary rehabilitation (Nakase-Richardson et al., 2013) all contributed to the successful outcome for this patient despite the challenges of caring for severe TBI cases in a remote, austere environment.
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If the clinical investigation is deemed research, a formal institutional review board review must be conducted. While initially drawing heavily on civilian sector best practice guidelines for care of brain trauma (e.g., Brain Trauma Foundation guidelines)
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. In this study, military TBI patients in the DoDTR meeting inclusion criteria were propensity matched to similar patients from the National Trauma Data Bank (DuBose et al., 2011)
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1996. Tactical combat casualty care in special operations.
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2012. Long-term outcomes of combat casualties sustaining penetrating traumatic brain injury.
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