ABSTRACT

Background: Thoracic trauma occurs frequently in combat and is associated with high mortality. Tube thoracostomy (chest tube) is the treatment for pneumothorax resulting from thoracic trauma, but little data exist to characterize combat casualties undergoing this intervention. We sought to describe the incidence of these injuries and procedures to inform training and materiel development priorities. Methods: This is a secondary analysis of a Department of Defense Trauma Registry (DoDTR) data set from 2007 to 2020 describing prehospital care within all theaters in the registry. We described all casualties who received a tube thoracostomy within 24 hours of admission to a military treatment facility. Variables described included casualty demographics; abbreviated injury scale (AIS) score by body region, presented as binary serious (=3) or not serious (<3); and prehospital interventions. Results: The database identified 25,897 casualties, 2,178 (8.4%) of whom received a tube thoracostomy within 24 hours of admission. Of those casualties, the body regions with the highest proportions of common serious injury (AIS >3) were thorax 62% (1,351), extremities 29% (629), abdomen 22% (473), and head/neck 22% (473). Of those casualties, 13% (276) had prehospital needle thoracostomies performed, and 19% (416) had limb tourniquets placed. Most of the patients were male (97%), partner forces members or humanitarian casualties (70%), and survived to discharge (87%). Conclusions: Combat casualties with chest trauma often have multiple injuries complicating prehospital and hospital care. Explosions and gunshot wounds are common mechanisms of injury associated with the need for tube thoracostomy, and these interventions are often performed by enlisted medical personnel. Future efforts should be made to provide a correlation between chest interventions and pneumothorax management in prehospital thoracic trauma.

Incidence of Traumatic Brain Injuries within the Prehospital Trauma Registry System

Braden SF, Long B, Rizzo J, April MD, Dengler BA, Schauer S. 24(2). 24 - 33. (Journal Article)

ABSTRACT

Background: Traumatic brain injury (TBI) is often underreported or undetected in prehospital civilian and military settings. This study evaluated the incidence of TBI within the Prehospital Trauma Registry (PHTR) system. Methods: We reviewed PHTR and the linked Department of Defense Trauma Registry (DoDTR) records of casualties from January 2003 through May 2019 for diagnostic data and surgical reports. Results: A total of 709 casualties met inclusion criteria. The most common mechanism was blast, including 328 (51%) in the non-TBI and 45 (63%) in the TBI cohorts. The median injury severity scores in the non-TBI and TBI cohorts were 5 and 14, respectively. The survival scores in the non-TBI and TBI cohorts were 98% and 92%, respectively. Subdural hematomas, followed by subarachnoid hemorrhages were the most common classifiable brain injuries. Other nonspecific TBIs occurred in 85% of the TBI cohort casualties. Seventy-two cases (10%) were documented by the Role 1 clinician. Based on coding or operative data, 15 of the 72 (21%) were identified as TBIs. Of the 637 cases, which could not be decided based on coding or operative data, TBI was suspected in 42 (7%) cases based on Role 1 records. Conclusions: Over 1 in 10 casualties presenting to a Role 1 facility had a TBI requiring transfer to a higher level of care. Our findings suggest the need for improved diagnostic technologies and documentation systems at Role 1 facilities for accurate TBI diagnosis and reporting.

ABSTRACT

Introduction: Maximizing the capabilities of available lowflow oxygen is key to providing adequate oxygen to prevent/treat hypoxemia and conserve oxygen. We designed a closed-circuit system that allows rebreathing of gases while scrubbing carbon dioxide (CO2) in conjunction with portable mechanical ventilators in a bench model. Methods: We evaluated the system using two portable mechanical ventilators currently deployed by the Department of Defense-Zoll 731 and AutoMedx SAVe II-over a range of ventilator settings and lung models, using 1 and 3L/min low-flow oxygen into a reservoir bag. We measured peak inspired oxygen concentration (FiO2), CO2-absorbent life, gas temperature and humidity, and the effect of airway suctioning and ventilator disconnection on FiO2 on ground and at altitude. Results: FiO2 was =0.9 across all ventilator settings and altitudes using both oxygen flows. CO2-absorbent life was >7 hours. Airway humidity range was 87%-97%. Mean airway temperature was 25.4°C (SD 0.5°C). Ten-second suctioning reduced FiO2 22%-48%. Thirtysecond ventilator disconnect reduced FiO2 29%-63% depending on oxygen flow used. Conclusion: Use of a rebreathing system with mechanical ventilation has the potential for oxygen conservation but requires diligent monitoring of inspired FiO2 and CO2 to avoid negative consequences.

Keywords: Mechanical Ventilation; oxygen; rebreathing; hypoxemia; transport

The JSOM podcast digs deeper into the articles and subjects that matter to our readers. Our podcast hosts, Captains Alex Merkle and Josh Randles, tackle articles from the journal based on merit, interest, and application for operators in the field. The Spring 24 episode is here!

Current Episode

Our JSOM podcast team will be reviewing the following articles for our Spring podcast: 

Development and Implementation of a Standard Operating Procedure for Military Working Dog Blood Collection, Storage, and Transport by Elizabeth L. Evernham, Benjamin T. Fedeles, and Kayla M. Knuf (https://www.jsomonline.org/FeatureArticle/2024128Evernham.pdf)

Derivation of a Procedural Performance Checklist for Bifemoral Veno-Venous Extracorporeal Membrane Oxygenation Cannula Placement in Operational Environments by Elizabeth Powell, Richard Betzold, et al. (https://www.jsomonline.org/FeatureArticle/2024132Powell.pdf)

Emergency Fresh Whole Blood Transfusion Training for Ukrainian Health Professionals in Austere Environments by Zachery L. Brown, Joshua P. Cuestas, Kevin J. Matthews, Jonathan T. Shumaker, Durwood W. Moore, and Rebekah Cole (https://www.jsomonline.org/FeatureArticle/2024138Brown.pdf)

JSOM Guest Editor Captain Cam Strawn reviews Development and Implementation of a Standard Operating Procedure for Military Working Dog Blood Collection, Storage, and Transport. Capt Strawn serves as an Air Force Combat Rescue Officer and combat veteran who teaches leadership as an Assistant Professor of Aerospace Studies at Brigham Young University, where he is also completing a premedical post-baccalaureate program. He is a SOFtoSOM Scholar applying to medical school this year.

JSOM Guest Authors

Emergency Fresh Whole Blood Transfusion Training for Ukrainian Health Professionals in Austere Environments authors SFC Zachery Brown and HM1 Kevin John Matthews are

interviewed by our podcaster team about their article. SFC Zachery Brown enlisted in the Army on 15 September 2009. He has served with the 75th Ranger Regiment for the past 13 years: 7 years in the 1st Ranger Battalion and 6 years in the Regimental Reconnaissance Company (RRC). He served as a Ranger Squad Leader, Regimental Reconnaissance Team (RRT) Medical Sergeant, RRT Assistant Team Sergeant, and RRC Operations NCOIC and has nine combat deployments to Afghanistan, Iraq, and Syria, amounting to over 500 Special Operations Raids. In 2021, the Uniformed Services University of Health Services (USUHS) selected him for one of seven Army slots for the 24-month Cohort 9, Enlisted to Medical Degree Preparatory Program (EMDP2). This program prepares top-performing enlisted Servicemembers to apply to medical school. He is currently enrolled as a graduate student and aims to continue serving our nation and global community as a military physician and medical officer in the United States Army. SFC Brown earned a BS in Biology, Bio-Engineering Concentration, from the University of Arkansas in 2008, an MS in Strategic Leadership from the University of Charleston, and is currently working towards completing an MS in Biology at George Mason University.

Hospital Corpsman First Class, HM1 (FMF/ SW) Kevin John Matthews enlisted in the Navy in 2016. Operationally, HM1 Matthews served as the Senior Line Corpsman, Scout Sniper Platoon, Weapons Company, 1st Battalion, 4th Marines, deploying to Africa and the Middle East aboard the 15th Marine Expeditionary Unit (MEU) in 2021. Upon returning from deployment, the Navy Education and Training Office (NETO) selected HM1 Matthews as a Combat Trauma Management and Valkyrie Emergency Fresh Whole Blood Transfusion training instructor. He oversees the training of all medical personnel attached to Marine Corps expeditionary ground forces at 1st Marine Division, Camp Pendleton, CA. Hand-selected by the Division Surgeon, he was appointed the founding Course Manager for the inaugural Prolonged Casualty Care Course, preparing forward-deployed Corpsmen to sustain casualties beyond the “Golden Hour” in resource-limited environments and austere terrain. In 2021, USUHS selected HM1 Matthews for one of seven Navy slots for the EMDP2. He is currently enrolled as a graduate student and aims to continue to serve our nation and global community as a physician and Medical Officer in the United States Navy. HM1 Matthews earned a BA in History, Middle Eastern Concentration, from the University of California San Diego in 2014 and worked as an EMT-B and Ocean Lifeguard for the San Diego Fire Rescue Department from 2014 to 2016. Additional current and prior professional qualifications include PHTLS, ABLS, TCCC Instructor, Personal Watercraft Operator for High-Surf Rescues, and AHA BLS Instructor. 

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For over 20 years, the Journal of Special Operations Medicine (JSOM) has brought important, lifesaving information to the Special Operations Forces (SOF) community. And over the years, as our audience and readership has expanded into over 80 countries, physicians, military and tactical medics, and other medical professionals working in unconventional environments rely on the JSOM for breakthrough research at the intersection of operational medicine and tactical casualty care. Our peer-reviewed research and interactive clinical content make the JSOM a must-read for:

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Coming Soon from the Journal of Special Operations Medicine published by Breakaway Media, LLC

We are excited to announce the upcoming publication of Tell Them Yourself: It's Not Your Day To Die*, by Frank Butler, Kevin O'Connor, and Jeff Butler.

It's an extraordinary, true account of how a small group of world-class trauma experts joined forces with America’s best combat medics to rewrite the battlefield medicine rule book and then sell these revolutionary new concepts to a disbelieving medical world.

This is the definitive record of how TCCC came to be and how these protocols forever changed the way care is provided to those wounded in combat, written by the men who fought for the change.

*This highly anticipated book will premiere at the 2024 Special Operations Medical Association symposium. Dr. Frank Butler will be at the JSOM booth #611 signing copies. The book will then be available to purchase on the JSOM website on or around May 20th.



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