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Military trauma

Date post: 24-Dec-2014
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Lessons for ED staff from the military management of severe trauma
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Why? A short history of military medicine Changing battlefields EBM, Better data sets Save before you can fix Resource constraints Drive to more efficient care Reduce Longterm dependancy
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Page 1: Military trauma

Why?

●A short history of military medicine–Changing battlefields–EBM, Better data sets–Save before you can fix–Resource constraints●Drive to more efficient care●Reduce Longterm dependancy

Page 2: Military trauma

Goal

To perform the correct intervention at the correct time in the continuum of Care to improve survival and reduce morbidity.

In other words, a medically correct intervention performed at the wrong time in the military continuum of care may lead to further casualties or worse outcomes

Page 3: Military trauma

Factors influencing combat casualty care

●Enemy Fire●Medical Equipment Limitations●Widely Variable Evacuation Time●Tyranny of numbers

Page 4: Military trauma

Principles of TCCC

• The three goals of Tactical Combat Casualty Care (TCCC) are:

–1. Save preventable deaths

–2. Prevent additional casualties

–3. Complete the mission

Page 5: Military trauma

Development

PhysiologyOf trauma

Principles oftrauma care

Risk tolerance

Principles ofTCCC

Trauma registry

Carepathway

Page 6: Military trauma

HowCONCEPT OF CARE Date : Version : 001

SELECT

MD 717 release policy

ENHANCE

REHAB PATHWAY

MONITOR

PREVENTPROTECT

ANALYSE

INCIDENT

REVIEW BOARD

REVISED Conditions of

Service

MAJOR PATHWAY

Minorpathway

RELEASE MANAGEMENT

RESIDUAL LIABILITY

Mitigateinnovate

Selection standards policyAppeal policyWaiver policyComplaints policy

Complex case policy

MD 715 Medical release policy

VANZ attributable policyNon VANZ attributable policyWelfare support policy

Revised conditions of service policy

Medical Review Board policy

Release process Instruction

Rehabilitation Policy

Acute incident management policiesPIP policy

Minor Health Intervention policy

Release Management policy

Physical conditioning policyMental conditioning policyPerformance aids policyHealth promotion policy

Health Risk assessment policy

Health Research policy

Health StandardsOSH policy

Health reporting policy

Page 7: Military trauma

Forensics

Page 8: Military trauma
Page 9: Military trauma

Improvisation

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Page 11: Military trauma
Page 12: Military trauma

Mid tour christmas Party

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Page 14: Military trauma

Parasitology

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Page 16: Military trauma

Ground Ambulance

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Page 23: Military trauma

MASH

Page 24: Military trauma
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Page 29: Military trauma

WHO?

●Changing patient–The 90/10 rule●WW1 90% mil 10% Civ, ●OIF/OEF 90% Civ 10% Mil

●Historically 90% non battle casualties (disease predominantly)●Modern conflicts 90% battle casualties

Page 30: Military trauma

Monthly Admissions by Facility

Bagram Kandahar Bastion Dwyer0

50

100

150

200

250

300

350 Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

04/10/2023 8Right Patient, Right Care, Right Place, Right Time

Page 31: Military trauma

OEF Total Trauma AdmissionsBattle vs. Non-Battle Injury

Apr-10

May

-10Jun-10

Jul-10

Aug-10

Sep-10

Oct-10

Nov-10

Dec-10

Jan-11

Feb-11

Mar-

110

100200300400500600700800900

1000

385

572725 743 722

627 589477

348 348 302448

126

93

120 117 111

8783

110

126 130114

150

Battle vs. Non-Battle Injury – 1 Year

Series3 Non-Battle (25%)

04/10/2023 12Right Patient, Right Care, Right Place, Right Time

Page 32: Military trauma
Page 33: Military trauma

How - Cause of InjuryMar 2011

148

10

23

6

249

717

2 14

63

9 44 Bullet/GSW/Firearm

Burn

Fall

Hand Grenade

IED

Knife/Other Sharp Object

Machinery/Equipment

Mine/Landmine

Mortar/Rocket/Artillery Shell

MVC

RPG

Other

04/10/2023 36Right Patient, Right Care, Right Place, Right Time

*Includes both battle and non-battle injury

Page 34: Military trauma
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Page 36: Military trauma

Trauma and The Lethal Triad

Acidosis Hypothermia

Coagulopathy

Death

Brohi, K, et al. J Trauma, 2003.

Page 37: Military trauma

Combat Deaths

•KIA: 31% Penetrating head trauma•KIA: 25% Surgically uncorrectable torso trauma•KIA: 10% Potentially surgically correctable trauma•KIA: 9% Hemorrhage from extremity wounds•KIA: 7% Mutilating blast trauma•KIA: 5% Tension pneumothorax•KIA: 1% Airway problems•12% Mostly from infections and complications of shock

Page 38: Military trauma

PREVENTABLE CAUSES OF COMBAT DEATH

•60% Hemorrhage from extremity wounds

•33% Tension pneumothorax

•6% Airway obstruction e.g., maxillofacial trauma

•* Data is extrapolated from Vietnam to present day Iraq and Afghanistan

Page 39: Military trauma

Survival80% survive

70% survive at 1 hour

60% survive to 24 hours

50% survive to 72 hours

20% die immediately

10% die over the first hour – Hg/Airway\

Further 10% die by 6 hours – lethal triad

10% die over the next 48 hours – lethal triad and late complications

Page 40: Military trauma

Summary

• There are three categories of casualties on the battlefield:

1. Operators who will live regardless

2. Operators who will die regardless

3. Operators who will die from preventable deaths unless there is intervention

• Target the intervention to the mechanism and time window

Page 41: Military trauma

CMAST 43

Injury severity

Page 42: Military trauma
Page 43: Military trauma
Page 44: Military trauma

OEF Shock on Admission (BD > 5)

OEF0

20

40

60

80

100

120

140Apr-10

May-10

Jun-10

Jul-10

Aug-10

Sep-10

Oct-10

Nov-10

Dec-10

Jan-11

Feb-11

Mar-11

13.3% of total OEF admissions

04/10/2023

18

Right Patient, Right Care, Right Place, Right Time

1-Year’s Data: Apr 10– Mar 11

Page 45: Military trauma
Page 46: Military trauma

OEF HypothermiaBreakdown

US Mil-itary

Coalition All Others

0

5

10

15

20

25

30

35

40

7

2

27

Admission Temperature < 96 F or < 35.5 C

Oct-10

Nov-10

Dec-10

Jan-11

Feb-11

Mar-11

1% of all US admissions

.3% of all Coalition admissions

04/10/2023 17Right Patient, Right Care, Right Place, Right Time

4.5% of all Others admissions

Page 47: Military trauma
Page 48: Military trauma

OEF TotalCasualties Requiring

Blood

Apr-10

May-10

Jun-10

Jul-1

0

Aug-10

Sep-10

Oct-10

Nov-10

Dec-10

Jan-11

Feb-11

Mar-1

10

20

40

60

80

100

120

140 (2050/7758= 26.4%)

US Mil 32% (N=663)

Coalition 11% (N=225)

Others 57% (N=1161)

Num

ber o

f Adm

issi

ons

04/10/2023 20Right Patient, Right Care, Right Place, Right Time

Page 49: Military trauma

Massive Transfusion Component Therapy

PRBC FFP Platelets Cryo RBC Age0

5

10

15

20

25

30

18.2 18.7

3.2 3.1

21

Mar 2011 MT Patients (N= 49)

Mean # units trans-fused

Mean RBC Age

Platelets: 1 unit = 6 pk plts

04/10/2023 25Right Patient, Right Care, Right Place, Right Time

Total Units FWB: 0Doses of Factor VII: 1 (Level III Only)

Page 50: Military trauma

OEF Level III Massive Transfusion

Survival

2nd Qtr 10 3nd Qtr 10 4th Qtr 10 1st Qtr 11 0

20

40

60

80

100

120

140

70%

75%

80%

85%

90%

95%

100%

# Massive Transfusions % Survival

# M

as

siv

e T

ran

sfu

sio

ns

% S

urv

iva

l

04/10/2023 23Right Patient, Right Care, Right Place, Right Time

Page 51: Military trauma

OEF Massive Transfusion Survival Long Term US Military Only

2nd Qtr 10 3rd Qtr 10 4th Qtr 10 1st Qtr 11 0

10

20

30

40

50

60

70

70%

75%

80%

85%

90%

95%

100%

# Massive Transfusions % Survival

# M

as

siv

e T

ran

sfu

sio

ns

% S

urv

iva

l

04/10/2023 18Right Patient, Right Care, Right Place, Right Time

Page 52: Military trauma

OEF Massive Transfusion Survival Long Term Coalition Only

2nd Qtr 10 3rd Qtr 10 4th Qtr 10 1st Qtr 11 0

10

20

30

40

50

60

70

70%

75%

80%

85%

90%

95%

100%

# Massive Transfusions % Survival

# M

as

siv

e T

ran

sfu

sio

ns

% S

urv

iva

l

04/10/2023 24Right Patient, Right Care, Right Place, Right Time

Page 53: Military trauma
Page 54: Military trauma
Page 55: Military trauma

More Complicated Than Anticipated – Acute Coagulopathy of Trauma Shock

25% of trauma patients present coagulopathic

Page 56: Military trauma
Page 57: Military trauma

WHERE

Platform agnostic

When is crucial to outcome, where is not.

Page 58: Military trauma
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Page 61: Military trauma

Putting it all together

Page 62: Military trauma

Concept of Medical Support

FAST

FIX 6 – 24 hours 80%

STABILISE 1 Hour 3% surgical

RESUSCITATE 15 Minutes 100%

SAVE 5 Minutes 100%

Fd HospFSSD

FASTBuddy Aid

CLS

Point of injury

Forward casualty Circulation

Rear casualty Circulation

17% Return to duty 72 hours

SMART

Page 63: Military trauma

Questions?


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