Lanny Littlejohn | Uniformed Services University (original) (raw)

Papers by Lanny Littlejohn

Research paper thumbnail of Management of External Hemorrhage in Tactical Combat Casualty Care: Chitosan-Based Hemostatic Gauze Dressings

Journal of special operations medicine : a peer reviewed journal for SOF medical professionals, 2014

Hemorrhage remains the leading cause of combat death and a major cause of death from potentially ... more Hemorrhage remains the leading cause of combat death and a major cause of death from potentially survivable injuries. Great strides have been made in controlling extremity hemorrhage with tourniquets, but not all injuries are amenable to tourniquet application. Topical hemostatic agents and dressings have also contributed to success in controlling extremity and compressible junctional hemorrhage, and their efficacy continues to increase as enhanced products are developed. Since the addition of Combat Gauze ™ (Z-Medica Corporation, Wallingford, CT, USA; http://www.z-medica.com/) in April 2008 to the Tactical Combat Casualty Care (TCCC) Guidelines, there are consistent data from animal studies of severe hemorrhage that chitosan-based hemostatic gauze dressings developed for battlefield application are, at least, equally efficacious as Combat Gauze. Successful outcomes are also reported using newer chitosan-based dressings in civilian hospitalbased surgical case reports and prehospital (battlefield) case reports and series. Additionally, there have been no noted complications or safety concerns in these cases or across many years of chitosan-based hemostatic dressing use in both the military and civilian prehospital sectors. Consequently, after a decade of clinical use, there is added benefit and a good safety record for using chitosan-based gauze dressings. For these reasons, many specific US military Special Operations Forces, NATO militaries, and emergency medical services (EMS) and law enforcement agencies have already implemented the widespread use of these new recommended chitosanbased hemostatic dressings. Based on the past battlefield success, this report proposes to keep Combat Gauze as the hemostatic dressing of choice along with the new addition of Celox ™ Gauze (Medtrade Products Ltd.,

Research paper thumbnail of What a Special Operations Cognitive Assessment Should Look Like

Journal of special operations medicine : a peer reviewed journal for SOF medical professionals, 2023

Research paper thumbnail of Treatment of Thoracic Trauma: Lessons From the Battlefield Adapted to All Austere Environments

Wilderness & Environmental Medicine, Jun 1, 2017

Severe thoracic trauma in the backcountry can be a formidable injury pattern to successfully trea... more Severe thoracic trauma in the backcountry can be a formidable injury pattern to successfully treat. Traumatic open, pneumo-, and hemothoraces represent some of the most significant patterns for which advanced equipment and procedures may help leverage morbidity and mortality, particularly when evacuation is delayed and environmental conditions are extreme. This paper reviews the development of successful techniques for treating combat casualties with thoracic trauma, including the use of vented chest seals and the technique of needle thoracentesis. Recommendations are then given for applying this knowledge and skill set in the backcountry.

Research paper thumbnail of Observations on Tissue Culture of the Human Eye

Southern Medical Journal, Mar 1, 1956

Research paper thumbnail of Subdural Empyema Presenting with Seizure, Confusion, and Focal Weakness

Western Journal of Emergency Medicine, Dec 1, 2012

While sinusitis is a common ailment, intracranial suppurative complications of sinusitis are rare... more While sinusitis is a common ailment, intracranial suppurative complications of sinusitis are rare and difficult to diagnose and treat. The morbidity and mortality of intracranial complications of sinusitis have decreased significantly since the advent of antibiotics, but diseases such as subdural empyemas and intracranial abscesses still occur, and they require prompt diagnosis, treatment, and often surgical drainage to prevent death or long-term neurologic sequelae. We present a case of an immunocompetent adolescent male with a subdural empyema who presented with seizures, confusion, and focal arm weakness after a bout of sinusitis. [

Research paper thumbnail of Comparison of 4 Hemostatic Agents, CELOX-A, ChitoFlex, WoundStat, and Combat Gauze, Versus Standard Gauze Dressing in Control of Extremity Hemorrhage in a Limited Access Swine Model of Penetrating Combat Trauma

Wilderness & Environmental Medicine, Mar 1, 2010

Lake City, UT) mucosal atomizing device. Doses were administered in 1/6 dose increments in altern... more Lake City, UT) mucosal atomizing device. Doses were administered in 1/6 dose increments in alternating nares. Pain scores were recorded at 0, 2, 5, and 10 minutes using a verbally administered numerical rating scale of 0 through 10. Results.-Data analysis was performed using results from 42 of the 46 patients: 5 pediatric and 37 adult. Four patients were excluded due to incomplete data. Thirty-four patients were initially treated on-slope and 8 patients were initially treated in the clinic. Average weight-based dosage for intranasal fentanyl was 1.4 g/kg (95% confidence interval [CI]: 1.3-1.5 g/kg; n ϭ 42). The mean baseline pain score for all patients was 8.2 (95% CI: 7.7-8.7; n ϭ 42). Pain scores were significantly reduced after treatment with fentanyl. Mean pain score reduction at 2 minutes was Ϫ1.4 (95% CI: Ϫ2.0 to Ϫ0.96; n ϭ 41); at 5 minutes, Ϫ2.8 (95% CI: Ϫ3.5 to Ϫ2.1; nϭ42); at 10 minutes, Ϫ2.8 (95% CI: Ϫ3.7 to Ϫ1.9; n ϭ 29). No significant complications were noted. Conclusion.-Intranasal fentanyl provides effective analgesia in acutely injured patients and is a good option for patients in whom immediate intravenous access is complicated by environmental, anatomic, or resource limitations. The potential application for search-and-rescue and other austere medicine situations is widespread.

Research paper thumbnail of Models for Hemostatic Agent Testing: Control Versus Fidelity

Journal of Trauma-injury Infection and Critical Care, Sep 1, 2009

... Government. John J. Devlin, MD. Sara J. Kircher, BS, RLAT. Lanny F. Littlejohn, MD. Departmen... more ... Government. John J. Devlin, MD. Sara J. Kircher, BS, RLAT. Lanny F. Littlejohn, MD. Department of Emergency Medicine. Naval Medical Center. Portsmouth, VA. ... REFERENCES. 1. Kheirabadi BS, Edens JW, Terrazas IB, et al. Comparison ...

Research paper thumbnail of Swine Models of Hemorrhagic Shock: To Splenectomize or Not to Splenectomize, That is the Question

Journal of Trauma-injury Infection and Critical Care, Oct 1, 2009

Research paper thumbnail of Terlipressin with Limited Fluid Resuscitation in a Swine Model of Hemorrhage

The Journal of emergency medicine, Jul 1, 2013

Background: Principles of damage control resuscitation include minimizing intravenous fluid (IVF)... more Background: Principles of damage control resuscitation include minimizing intravenous fluid (IVF) administration while correcting perfusion pressure as quickly as possible. Recent studies have identified a potential advantage of vasopressin over catecholamines in traumatic shock. Terlipressin (TP) is a vasopressin analogue used to reverse certain shock etiologies in some European countries. Study Objective: We evaluated three dosages of TP when combined with a limited colloid resuscitation strategy on mean arterial pressure (MAP) and lactatemia in a swine model of isolated hemorrhage. Methods: Sixty anesthetized swine underwent intubation and severe hemorrhage. Subjects were randomized to one of four resuscitation groups: 4 mL/kg Hextend Ò (Hospira Inc, Lake Forest, IL) only, 3.75 mg/kg TP + Hextend, 7.5 mg/kg TP + Hextend, or 15 mg/kg TP + Hextend. MAP and heart rate were recorded every 5 min. Baseline and serial lactate values at 30-min intervals were recorded and compared. Results: Subjects receiving 7.5 mg/kg TP had significantly higher MAPs at times t 15 (p = 0.012), t 20 (p = 0.004), t 25 (p = 0.018), t 30 (p = 0.032), t 35 (p = 0.030), and t 40 (p = 0.021). No statistically significant differences in lactate values between TP groups and controls were observed. Conclusion: Subjects receiving 7.5 mg/kg of TP demonstrated improved MAP within 10 min of administration. When combined with minimal IVF resuscitation, TP doses between 3.75 and 15 mg/kg do not elevate lactate levels in hemorrhaged swine. Published by Elsevier Inc.

Research paper thumbnail of Control of Junctional Hemorrhage in a Consensus Swine Model With Hemostatic Gauze Products Following Minimal Training

Military Medicine, Nov 1, 2015

Objective: Uncontrolled hemorrhage from junctional wounds that cannot be controlled by traditiona... more Objective: Uncontrolled hemorrhage from junctional wounds that cannot be controlled by traditional tourniquets accounts for one in five preventable battlefield exsanguination deaths. Products for treating these wounds are costly and require special training. However, chemically treated gauze products are inexpensive, potentially effective, and require only minimal training. This study was designed to assess the efficacy of three hemostatic gauze products following brief training, using a consensus swine groin injury model. Methods: After viewing a 15-minute PowerPoint presentation, without demonstration or practice, 24 U.S. Navy Corpsmen, most with little to no live tissue or hemostatic agent experience, applied one of three hemostatic agents: QuikClot Combat Gauze, Celox Trauma Gauze, or Hemcon ChitoGauze. Animals were resuscitated and monitored for 150 minutes to assess initial hemostasis, blood loss, rebleeding, and survival. Participants completed a survey before training and following testing. Results: Products were similar in initial hemostasis, blood loss, and rebleeding. Twenty-three swine survived (96%). Ease of use and perceived efficacy of training ratings were high. Comfort level with application improved following training. Conclusions: Hemostatic gauze can potentially be effective for treating junctional wounds following minimal training, which has important implications for corpsmen, self-aid/buddy-aid, civilian providers, and Tactical Combat Casualty Care guidelines.

Research paper thumbnail of Vented Chest Seals for Prevention of Tension Pneumothorax in a Communicating Pneumothorax

The Journal of emergency medicine, Nov 1, 2013

Background: Tension pneumothorax accounts for 3%-4% of combat casualties and 10% of civilian ches... more Background: Tension pneumothorax accounts for 3%-4% of combat casualties and 10% of civilian chest trauma. Air entering a wound via a communicating pneumothorax rather than by the trachea can result in respiratory arrest and death. In such cases, the Committee on Tactical Combat Casualty Care advocates the use of unvented chest seals to prevent respiratory compromise. Objective: A comparison of three commercially available vented chest seals was undertaken to evaluate the efficacy of tension pneumothorax prevention after seal application. Methods: A surgical thoracostomy was created and sealed by placing a shortened 10-mL syringe barrel (with plunger in place) into the wound. Tension pneumothorax was achieved via air introduction through a Cordis to a maximum volume of 50 mL/kg. A 20% drop in mean arterial pressure or a 20% increase in heart rate confirmed hemodynamic compromise. After evacuation, one of three vented chest seals (HyFin Ò , n = 8; Sentinel Ò , n = 8, SAM Ò , n = 8) was applied. Air was injected to a maximum of 50 mL/kg twice, followed by a 10% autologous blood infusion, and finally, a third 50 mL/kg air bolus. Survivors completed all three interventions, and a 15-min recovery period. Results: The introduction of 29.0 (±11.5) mL/kg of air resulted in tension physiology. All three seals effectively evacuated air and blood. Hemodynamic compromise failed to develop with a chest seal in place. Conclusions: HyFin Ò , SAM Ò , and Sentinel Ò vented chest seals are equally effective in evacuating blood and air in a communicating pneumothorax model. All three prevented tension pneumothorax formation after penetrating thoracic trauma. Published by Elsevier Inc.

Research paper thumbnail of Effects of Training and Simulated Combat Stress on Leg Tourniquet Application Accuracy, Time, and Effectiveness

Military Medicine, Feb 1, 2014

The lower extremity tourniquet failure rate remains significantly higher in combat than in precli... more The lower extremity tourniquet failure rate remains significantly higher in combat than in preclinical testing, so we hypothesized that tourniquet placement accuracy, speed, and effectiveness would improve during training and decline during simulated combat. Navy Hospital Corpsman (N = 89), enrolled in a Tactical Combat Casualty Care training course in preparation for deployment, applied Combat Application Tourniquet (CAT) and the Special Operations Forces Tactical Tourniquet (SOFT-T) on day 1 and day 4 of classroom training, then under simulated combat, wherein participants ran an obstacle course to apply a tourniquet while wearing full body armor and avoiding simulated small arms fire (paint balls). Application time and pulse elimination effectiveness improved day 1 to day 4 (p 0.005). Under simulated combat, application time slowed significantly (p 0.001), whereas accuracy and effectiveness declined slightly. Pulse elimination was poor for CAT (25% failure) and SOFT-T (60% failure) even in classroom conditions following training. CAT was more quickly applied (p 0.005) and more effective (p 0.002) than SOFT-T. Training fostered fast and effective application of leg tourniquets while performance declined under simulated combat. The inherent efficacy of tourniquet products contributes to high failure rates under combat conditions, pointing to the need for superior tourniquets and for rigorous deployment preparation training in simulated combat scenarios.

Research paper thumbnail of Management of Open Pneumothorax in Tactical Combat Casualty Care: TCCC Guidelines Change 13-02

Journal of special operations medicine : a peer reviewed journal for SOF medical professionals, 2013

During the recent United States Central Command (US-CENTCOM) and Joint Trauma System (JTS) assess... more During the recent United States Central Command (US-CENTCOM) and Joint Trauma System (JTS) assessment of prehospital trauma care in Afghanistan, the deployed director of the Joint Theater Trauma System (JTTS), CAPT Donald R. Bennett, questioned why TCCC recommends treating a nonlethal injury (open pneumothorax) with an intervention (a nonvented chest seal) that could produce a lethal condition (tension pneumothorax). New research from the U.S. Army Institute of Surgical Research (USAISR) has found that, in a model of open pneumothorax treated with a chest seal in which increments of air were added to the pleural space to simulate an air leak from an injured lung, use of a vented chest seal prevented the subsequent development of a tension pneumothorax, whereas use of a nonvented chest seal did not. The updated TCCC Guideline for the battlefield management of open pneumothorax is: "All open and/ or sucking chest wounds should be treated by immediately applying a vented chest seal to cover the defect. If a vented chest seal is not available, use a non-vented chest seal. Monitor the casualty for the potential development of a subsequent tension pneumothorax. If the casualty develops increasing hypoxia, respiratory distress, or hypotension and a tension pneumothorax is suspected, treat by burping or removing the dressing or by needle decompression." This recommendation was approved by the required two-thirds majority of the Committee on TCCC in June 2013.

Research paper thumbnail of Application of Current Hemorrhage Control Techniques for Backcountry Care: Part One, Tourniquets and Hemorrhage Control Adjuncts

Wilderness & Environmental Medicine, Jun 1, 2015

Decade-long advancements in battlefield medicine have revolutionized the treatment of traumatic h... more Decade-long advancements in battlefield medicine have revolutionized the treatment of traumatic hemorrhage and have led to a significant reduction in mortality. Older methods such as limb elevation and pressure points are no longer recommended. Tourniquets have had a profound effect on lives saved without the commonly feared safety issues that have made them controversial. Unique tourniquet designs for inguinal and abdominal regions are now available for areas not amenable to current fielded extremity tourniquets. This article, the first of two parts, reviews the literature for advancements in prehospital hemorrhage control for any provider in the austere setting. It emphasizes the significant evidence-based advances in tourniquet use on the extremities that have occurred in battlefield trauma medicine since 2001 and reviews the newer junctional tourniquet devices. Recommendations are made for equipment and techniques for controlling hemorrhage in the wilderness setting.

Research paper thumbnail of Management of Suspected Tension Pneumothorax in Tactical Combat Casualty Care: TCCC Guidelines Change 17-02

Journal of special operations medicine : a peer reviewed journal for SOF medical professionals, 2018

Research paper thumbnail of Application of Current Hemorrhage Control Techniques for Backcountry Care: Part Two, Hemostatic Dressings and Other Adjuncts

Wilderness & Environmental Medicine, Jun 1, 2015

Decade-long advances in battlefield medicine have revolutionized the treatment of traumatic hemor... more Decade-long advances in battlefield medicine have revolutionized the treatment of traumatic hemorrhage and have led to a significant reduction in mortality. Part one of this review covered the use of tourniquets on the extremities and the newer devices for use in junctional areas. Part two focuses on the use of hemostatic agents or dressings, pelvic binders, and tranexamic acid. Field applicable hemostatic dressings are safe and effective in controlling hemorrhage not amenable to extremity tourniquet application, and newer agents with increasing efficacy continue to be developed. Most of these agents are inexpensive and lightweight, making them ideal products for use in wilderness medicine. The use of pelvic binders to stabilize suspected pelvic fractures has gained new interest as these products are developed and refined, and the prehospital use of tranexamic acid, a potent antifibrinolytic, has been found to be life saving in patients at risk of death from severe hemorrhage. Recommendations are made for equipment and techniques for controlling hemorrhage in the wilderness setting.

Research paper thumbnail of Comparison of ChitoFlex®, CELOX™, and QuikClot® in Control of Hemorrhage

The Journal of emergency medicine, Apr 1, 2009

Background: Exsanguinating extremity wounds remain the primary source of battlefield mortality. O... more Background: Exsanguinating extremity wounds remain the primary source of battlefield mortality. Operating forces employ three agents in Iraq: HemCon® (HemCon Medical Technologies, Inc., Portland, OR), QuikClot® (Z-Medica Corporation, Wallingford, CT), and CELOX™ (SAM Medical, Tualatin, OR). Anecdotal reports suggest that these agents are less useful on small entrance, linear-tract injuries. ChitoFlex® (HemCon Medical Technologies, Inc., Portland, OR) has been introduced but is untested. Study Objectives: To compare the equivalency of the ChitoFlex® dressing, QuikClot® ACS؉™ dressing, CELOX™, and standard gauze in their effectiveness to control bleeding from non-cavitary groin wounds. Methods: Forty-eight swine were randomly assigned to one of four treatment groups: standard gauze dressing (SD), ChitoFlex® dressing (CF), QuikClot® ACS؉™ dressing (QC), and CELOX™ dressing (CX). A groin injury with limited vessel access was created in each animal. Subjects were resuscitated with 500 mL of hetastarch. The primary endpoint was 180-min survival. Secondary endpoints included total blood loss in mL/kg, incidence of re-bleeding, survival times among the animals that did not survive for 180 min, failure to achieve initial hemostasis, incidence of recurrent bleeding, time to initial re-bleeding, amount of re-bleeding, and mass of residual hematoma. Results: Survival occurred in 10 of 12 SD animals, 10 of 12 CF animals, 10 of 12 QC animals, and 9 of 12 CX animals. No statistically significant difference was found. Conclusion: In our study of limited-access extremity bleeding, ChitoFlex® performed equally well in mitigating blood loss and promoting survival. The ChitoFlex® dressing is an equally effective alternative to currently available hemostatic agents. However, no agents were superior to standard gauze in our model of limited access. Published by Elsevier Inc.

Research paper thumbnail of Comparison of Celox-A, ChitoFlex, WoundStat, and Combat Gauze Hemostatic Agents Versus Standard Gauze Dressing in Control of Hemorrhage in a Swine Model of Penetrating Trauma

Academic Emergency Medicine, Apr 1, 2011

Objectives: Uncontrolled hemorrhage remains one of the leading causes of trauma deaths and one of... more Objectives: Uncontrolled hemorrhage remains one of the leading causes of trauma deaths and one of the most challenging problems facing emergency medical professionals. Several hemostatic agents have emerged as effective adjuncts in controlling extremity hemorrhage. However, a review of the current literature indicates that none of these agents have proven superior under all conditions and in all wound types. This study compared several hemostatic agents in a lethal penetrating groin wound model where the bleeding site could not be visualized. Methods: A complex groin injury with a small penetrating wound, followed by transection of the femoral vessels and 45 seconds of uncontrolled hemorrhage, was created in 80 swine. The animals were then randomized to five treatment groups (16 animals each). Group 1 was Celox-A (CA), group 2 was combat gauze (CG), group 3 was Chitoflex (CF), group 4 was WoundStat (WS), and group 5 was standard gauze (SG) dressing. Each agent was applied with 5 minutes of manual pressure. Hetastarch (500 mL) was infused over 30 minutes. Hemodynamic parameters were recorded over 180 minutes. Primary endpoints were attainment of initial hemostasis and incidence of rebleeding. Results: Overall, no difference was found among the agents with respect to initial hemostasis, rebleeding, and survival. Localizing effects among the granular agents, with and without delivery mechanisms, revealed that WS performed more poorly in initial hemostasis and survival when compared to CA.

Research paper thumbnail of Review of New Topical Hemostatic Dressings for Combat Casualty Care

Military Medicine, May 1, 2014

This review analyzes the new (2008-2013) hemostatic agents and dressings for enhanced efficacy in... more This review analyzes the new (2008-2013) hemostatic agents and dressings for enhanced efficacy in preclinical studies, and investigates supportive findings among case reports of effectiveness and safety in hospital and prehospital literature. A literature search was conducted using PubMed, National Library of Medicine using key words and phrases. The search revealed a total of 16 articles that fit the criteria established for third-generation hemostatic dressings. There were a total of 9 preclinical, 5 clinical, and 2 prehospital studies evaluated. Evaluation of these third-generation studies reveals that mucoadhesive (chitosan) dressings, particularly Celox Gauze and ChitoGauze, clearly show equal efficacy to Combat Gauze across many dependent variables. Chitosan-based products are ideal prehospital dressings because they are shown to work independently from the physiological clotting mechanisms. Many first-, second-, and third-generation chitosan-based dressings have been in use for years by the United States and other NATO militaries at the point of injury, and during tactical evacuation, in Operation Enduring Freedom and Operation Iraqi Freedom without reported complications or side effects. Based on the reported efficacy and long-term safety of chitosan-based products, increased use of Celox Gauze and ChitoGauze within the Department of Defense and civilian venues merits further consideration and open debate.

Research paper thumbnail of How the Five Principles of High Reliability Organizations Align with the Five Truths of Special Operations

Journal of Special Operations Medicine

Research paper thumbnail of Management of External Hemorrhage in Tactical Combat Casualty Care: Chitosan-Based Hemostatic Gauze Dressings

Journal of special operations medicine : a peer reviewed journal for SOF medical professionals, 2014

Hemorrhage remains the leading cause of combat death and a major cause of death from potentially ... more Hemorrhage remains the leading cause of combat death and a major cause of death from potentially survivable injuries. Great strides have been made in controlling extremity hemorrhage with tourniquets, but not all injuries are amenable to tourniquet application. Topical hemostatic agents and dressings have also contributed to success in controlling extremity and compressible junctional hemorrhage, and their efficacy continues to increase as enhanced products are developed. Since the addition of Combat Gauze ™ (Z-Medica Corporation, Wallingford, CT, USA; http://www.z-medica.com/) in April 2008 to the Tactical Combat Casualty Care (TCCC) Guidelines, there are consistent data from animal studies of severe hemorrhage that chitosan-based hemostatic gauze dressings developed for battlefield application are, at least, equally efficacious as Combat Gauze. Successful outcomes are also reported using newer chitosan-based dressings in civilian hospitalbased surgical case reports and prehospital (battlefield) case reports and series. Additionally, there have been no noted complications or safety concerns in these cases or across many years of chitosan-based hemostatic dressing use in both the military and civilian prehospital sectors. Consequently, after a decade of clinical use, there is added benefit and a good safety record for using chitosan-based gauze dressings. For these reasons, many specific US military Special Operations Forces, NATO militaries, and emergency medical services (EMS) and law enforcement agencies have already implemented the widespread use of these new recommended chitosanbased hemostatic dressings. Based on the past battlefield success, this report proposes to keep Combat Gauze as the hemostatic dressing of choice along with the new addition of Celox ™ Gauze (Medtrade Products Ltd.,

Research paper thumbnail of What a Special Operations Cognitive Assessment Should Look Like

Journal of special operations medicine : a peer reviewed journal for SOF medical professionals, 2023

Research paper thumbnail of Treatment of Thoracic Trauma: Lessons From the Battlefield Adapted to All Austere Environments

Wilderness & Environmental Medicine, Jun 1, 2017

Severe thoracic trauma in the backcountry can be a formidable injury pattern to successfully trea... more Severe thoracic trauma in the backcountry can be a formidable injury pattern to successfully treat. Traumatic open, pneumo-, and hemothoraces represent some of the most significant patterns for which advanced equipment and procedures may help leverage morbidity and mortality, particularly when evacuation is delayed and environmental conditions are extreme. This paper reviews the development of successful techniques for treating combat casualties with thoracic trauma, including the use of vented chest seals and the technique of needle thoracentesis. Recommendations are then given for applying this knowledge and skill set in the backcountry.

Research paper thumbnail of Observations on Tissue Culture of the Human Eye

Southern Medical Journal, Mar 1, 1956

Research paper thumbnail of Subdural Empyema Presenting with Seizure, Confusion, and Focal Weakness

Western Journal of Emergency Medicine, Dec 1, 2012

While sinusitis is a common ailment, intracranial suppurative complications of sinusitis are rare... more While sinusitis is a common ailment, intracranial suppurative complications of sinusitis are rare and difficult to diagnose and treat. The morbidity and mortality of intracranial complications of sinusitis have decreased significantly since the advent of antibiotics, but diseases such as subdural empyemas and intracranial abscesses still occur, and they require prompt diagnosis, treatment, and often surgical drainage to prevent death or long-term neurologic sequelae. We present a case of an immunocompetent adolescent male with a subdural empyema who presented with seizures, confusion, and focal arm weakness after a bout of sinusitis. [

Research paper thumbnail of Comparison of 4 Hemostatic Agents, CELOX-A, ChitoFlex, WoundStat, and Combat Gauze, Versus Standard Gauze Dressing in Control of Extremity Hemorrhage in a Limited Access Swine Model of Penetrating Combat Trauma

Wilderness & Environmental Medicine, Mar 1, 2010

Lake City, UT) mucosal atomizing device. Doses were administered in 1/6 dose increments in altern... more Lake City, UT) mucosal atomizing device. Doses were administered in 1/6 dose increments in alternating nares. Pain scores were recorded at 0, 2, 5, and 10 minutes using a verbally administered numerical rating scale of 0 through 10. Results.-Data analysis was performed using results from 42 of the 46 patients: 5 pediatric and 37 adult. Four patients were excluded due to incomplete data. Thirty-four patients were initially treated on-slope and 8 patients were initially treated in the clinic. Average weight-based dosage for intranasal fentanyl was 1.4 g/kg (95% confidence interval [CI]: 1.3-1.5 g/kg; n ϭ 42). The mean baseline pain score for all patients was 8.2 (95% CI: 7.7-8.7; n ϭ 42). Pain scores were significantly reduced after treatment with fentanyl. Mean pain score reduction at 2 minutes was Ϫ1.4 (95% CI: Ϫ2.0 to Ϫ0.96; n ϭ 41); at 5 minutes, Ϫ2.8 (95% CI: Ϫ3.5 to Ϫ2.1; nϭ42); at 10 minutes, Ϫ2.8 (95% CI: Ϫ3.7 to Ϫ1.9; n ϭ 29). No significant complications were noted. Conclusion.-Intranasal fentanyl provides effective analgesia in acutely injured patients and is a good option for patients in whom immediate intravenous access is complicated by environmental, anatomic, or resource limitations. The potential application for search-and-rescue and other austere medicine situations is widespread.

Research paper thumbnail of Models for Hemostatic Agent Testing: Control Versus Fidelity

Journal of Trauma-injury Infection and Critical Care, Sep 1, 2009

... Government. John J. Devlin, MD. Sara J. Kircher, BS, RLAT. Lanny F. Littlejohn, MD. Departmen... more ... Government. John J. Devlin, MD. Sara J. Kircher, BS, RLAT. Lanny F. Littlejohn, MD. Department of Emergency Medicine. Naval Medical Center. Portsmouth, VA. ... REFERENCES. 1. Kheirabadi BS, Edens JW, Terrazas IB, et al. Comparison ...

Research paper thumbnail of Swine Models of Hemorrhagic Shock: To Splenectomize or Not to Splenectomize, That is the Question

Journal of Trauma-injury Infection and Critical Care, Oct 1, 2009

Research paper thumbnail of Terlipressin with Limited Fluid Resuscitation in a Swine Model of Hemorrhage

The Journal of emergency medicine, Jul 1, 2013

Background: Principles of damage control resuscitation include minimizing intravenous fluid (IVF)... more Background: Principles of damage control resuscitation include minimizing intravenous fluid (IVF) administration while correcting perfusion pressure as quickly as possible. Recent studies have identified a potential advantage of vasopressin over catecholamines in traumatic shock. Terlipressin (TP) is a vasopressin analogue used to reverse certain shock etiologies in some European countries. Study Objective: We evaluated three dosages of TP when combined with a limited colloid resuscitation strategy on mean arterial pressure (MAP) and lactatemia in a swine model of isolated hemorrhage. Methods: Sixty anesthetized swine underwent intubation and severe hemorrhage. Subjects were randomized to one of four resuscitation groups: 4 mL/kg Hextend Ò (Hospira Inc, Lake Forest, IL) only, 3.75 mg/kg TP + Hextend, 7.5 mg/kg TP + Hextend, or 15 mg/kg TP + Hextend. MAP and heart rate were recorded every 5 min. Baseline and serial lactate values at 30-min intervals were recorded and compared. Results: Subjects receiving 7.5 mg/kg TP had significantly higher MAPs at times t 15 (p = 0.012), t 20 (p = 0.004), t 25 (p = 0.018), t 30 (p = 0.032), t 35 (p = 0.030), and t 40 (p = 0.021). No statistically significant differences in lactate values between TP groups and controls were observed. Conclusion: Subjects receiving 7.5 mg/kg of TP demonstrated improved MAP within 10 min of administration. When combined with minimal IVF resuscitation, TP doses between 3.75 and 15 mg/kg do not elevate lactate levels in hemorrhaged swine. Published by Elsevier Inc.

Research paper thumbnail of Control of Junctional Hemorrhage in a Consensus Swine Model With Hemostatic Gauze Products Following Minimal Training

Military Medicine, Nov 1, 2015

Objective: Uncontrolled hemorrhage from junctional wounds that cannot be controlled by traditiona... more Objective: Uncontrolled hemorrhage from junctional wounds that cannot be controlled by traditional tourniquets accounts for one in five preventable battlefield exsanguination deaths. Products for treating these wounds are costly and require special training. However, chemically treated gauze products are inexpensive, potentially effective, and require only minimal training. This study was designed to assess the efficacy of three hemostatic gauze products following brief training, using a consensus swine groin injury model. Methods: After viewing a 15-minute PowerPoint presentation, without demonstration or practice, 24 U.S. Navy Corpsmen, most with little to no live tissue or hemostatic agent experience, applied one of three hemostatic agents: QuikClot Combat Gauze, Celox Trauma Gauze, or Hemcon ChitoGauze. Animals were resuscitated and monitored for 150 minutes to assess initial hemostasis, blood loss, rebleeding, and survival. Participants completed a survey before training and following testing. Results: Products were similar in initial hemostasis, blood loss, and rebleeding. Twenty-three swine survived (96%). Ease of use and perceived efficacy of training ratings were high. Comfort level with application improved following training. Conclusions: Hemostatic gauze can potentially be effective for treating junctional wounds following minimal training, which has important implications for corpsmen, self-aid/buddy-aid, civilian providers, and Tactical Combat Casualty Care guidelines.

Research paper thumbnail of Vented Chest Seals for Prevention of Tension Pneumothorax in a Communicating Pneumothorax

The Journal of emergency medicine, Nov 1, 2013

Background: Tension pneumothorax accounts for 3%-4% of combat casualties and 10% of civilian ches... more Background: Tension pneumothorax accounts for 3%-4% of combat casualties and 10% of civilian chest trauma. Air entering a wound via a communicating pneumothorax rather than by the trachea can result in respiratory arrest and death. In such cases, the Committee on Tactical Combat Casualty Care advocates the use of unvented chest seals to prevent respiratory compromise. Objective: A comparison of three commercially available vented chest seals was undertaken to evaluate the efficacy of tension pneumothorax prevention after seal application. Methods: A surgical thoracostomy was created and sealed by placing a shortened 10-mL syringe barrel (with plunger in place) into the wound. Tension pneumothorax was achieved via air introduction through a Cordis to a maximum volume of 50 mL/kg. A 20% drop in mean arterial pressure or a 20% increase in heart rate confirmed hemodynamic compromise. After evacuation, one of three vented chest seals (HyFin Ò , n = 8; Sentinel Ò , n = 8, SAM Ò , n = 8) was applied. Air was injected to a maximum of 50 mL/kg twice, followed by a 10% autologous blood infusion, and finally, a third 50 mL/kg air bolus. Survivors completed all three interventions, and a 15-min recovery period. Results: The introduction of 29.0 (±11.5) mL/kg of air resulted in tension physiology. All three seals effectively evacuated air and blood. Hemodynamic compromise failed to develop with a chest seal in place. Conclusions: HyFin Ò , SAM Ò , and Sentinel Ò vented chest seals are equally effective in evacuating blood and air in a communicating pneumothorax model. All three prevented tension pneumothorax formation after penetrating thoracic trauma. Published by Elsevier Inc.

Research paper thumbnail of Effects of Training and Simulated Combat Stress on Leg Tourniquet Application Accuracy, Time, and Effectiveness

Military Medicine, Feb 1, 2014

The lower extremity tourniquet failure rate remains significantly higher in combat than in precli... more The lower extremity tourniquet failure rate remains significantly higher in combat than in preclinical testing, so we hypothesized that tourniquet placement accuracy, speed, and effectiveness would improve during training and decline during simulated combat. Navy Hospital Corpsman (N = 89), enrolled in a Tactical Combat Casualty Care training course in preparation for deployment, applied Combat Application Tourniquet (CAT) and the Special Operations Forces Tactical Tourniquet (SOFT-T) on day 1 and day 4 of classroom training, then under simulated combat, wherein participants ran an obstacle course to apply a tourniquet while wearing full body armor and avoiding simulated small arms fire (paint balls). Application time and pulse elimination effectiveness improved day 1 to day 4 (p 0.005). Under simulated combat, application time slowed significantly (p 0.001), whereas accuracy and effectiveness declined slightly. Pulse elimination was poor for CAT (25% failure) and SOFT-T (60% failure) even in classroom conditions following training. CAT was more quickly applied (p 0.005) and more effective (p 0.002) than SOFT-T. Training fostered fast and effective application of leg tourniquets while performance declined under simulated combat. The inherent efficacy of tourniquet products contributes to high failure rates under combat conditions, pointing to the need for superior tourniquets and for rigorous deployment preparation training in simulated combat scenarios.

Research paper thumbnail of Management of Open Pneumothorax in Tactical Combat Casualty Care: TCCC Guidelines Change 13-02

Journal of special operations medicine : a peer reviewed journal for SOF medical professionals, 2013

During the recent United States Central Command (US-CENTCOM) and Joint Trauma System (JTS) assess... more During the recent United States Central Command (US-CENTCOM) and Joint Trauma System (JTS) assessment of prehospital trauma care in Afghanistan, the deployed director of the Joint Theater Trauma System (JTTS), CAPT Donald R. Bennett, questioned why TCCC recommends treating a nonlethal injury (open pneumothorax) with an intervention (a nonvented chest seal) that could produce a lethal condition (tension pneumothorax). New research from the U.S. Army Institute of Surgical Research (USAISR) has found that, in a model of open pneumothorax treated with a chest seal in which increments of air were added to the pleural space to simulate an air leak from an injured lung, use of a vented chest seal prevented the subsequent development of a tension pneumothorax, whereas use of a nonvented chest seal did not. The updated TCCC Guideline for the battlefield management of open pneumothorax is: "All open and/ or sucking chest wounds should be treated by immediately applying a vented chest seal to cover the defect. If a vented chest seal is not available, use a non-vented chest seal. Monitor the casualty for the potential development of a subsequent tension pneumothorax. If the casualty develops increasing hypoxia, respiratory distress, or hypotension and a tension pneumothorax is suspected, treat by burping or removing the dressing or by needle decompression." This recommendation was approved by the required two-thirds majority of the Committee on TCCC in June 2013.

Research paper thumbnail of Application of Current Hemorrhage Control Techniques for Backcountry Care: Part One, Tourniquets and Hemorrhage Control Adjuncts

Wilderness & Environmental Medicine, Jun 1, 2015

Decade-long advancements in battlefield medicine have revolutionized the treatment of traumatic h... more Decade-long advancements in battlefield medicine have revolutionized the treatment of traumatic hemorrhage and have led to a significant reduction in mortality. Older methods such as limb elevation and pressure points are no longer recommended. Tourniquets have had a profound effect on lives saved without the commonly feared safety issues that have made them controversial. Unique tourniquet designs for inguinal and abdominal regions are now available for areas not amenable to current fielded extremity tourniquets. This article, the first of two parts, reviews the literature for advancements in prehospital hemorrhage control for any provider in the austere setting. It emphasizes the significant evidence-based advances in tourniquet use on the extremities that have occurred in battlefield trauma medicine since 2001 and reviews the newer junctional tourniquet devices. Recommendations are made for equipment and techniques for controlling hemorrhage in the wilderness setting.

Research paper thumbnail of Management of Suspected Tension Pneumothorax in Tactical Combat Casualty Care: TCCC Guidelines Change 17-02

Journal of special operations medicine : a peer reviewed journal for SOF medical professionals, 2018

Research paper thumbnail of Application of Current Hemorrhage Control Techniques for Backcountry Care: Part Two, Hemostatic Dressings and Other Adjuncts

Wilderness & Environmental Medicine, Jun 1, 2015

Decade-long advances in battlefield medicine have revolutionized the treatment of traumatic hemor... more Decade-long advances in battlefield medicine have revolutionized the treatment of traumatic hemorrhage and have led to a significant reduction in mortality. Part one of this review covered the use of tourniquets on the extremities and the newer devices for use in junctional areas. Part two focuses on the use of hemostatic agents or dressings, pelvic binders, and tranexamic acid. Field applicable hemostatic dressings are safe and effective in controlling hemorrhage not amenable to extremity tourniquet application, and newer agents with increasing efficacy continue to be developed. Most of these agents are inexpensive and lightweight, making them ideal products for use in wilderness medicine. The use of pelvic binders to stabilize suspected pelvic fractures has gained new interest as these products are developed and refined, and the prehospital use of tranexamic acid, a potent antifibrinolytic, has been found to be life saving in patients at risk of death from severe hemorrhage. Recommendations are made for equipment and techniques for controlling hemorrhage in the wilderness setting.

Research paper thumbnail of Comparison of ChitoFlex®, CELOX™, and QuikClot® in Control of Hemorrhage

The Journal of emergency medicine, Apr 1, 2009

Background: Exsanguinating extremity wounds remain the primary source of battlefield mortality. O... more Background: Exsanguinating extremity wounds remain the primary source of battlefield mortality. Operating forces employ three agents in Iraq: HemCon® (HemCon Medical Technologies, Inc., Portland, OR), QuikClot® (Z-Medica Corporation, Wallingford, CT), and CELOX™ (SAM Medical, Tualatin, OR). Anecdotal reports suggest that these agents are less useful on small entrance, linear-tract injuries. ChitoFlex® (HemCon Medical Technologies, Inc., Portland, OR) has been introduced but is untested. Study Objectives: To compare the equivalency of the ChitoFlex® dressing, QuikClot® ACS؉™ dressing, CELOX™, and standard gauze in their effectiveness to control bleeding from non-cavitary groin wounds. Methods: Forty-eight swine were randomly assigned to one of four treatment groups: standard gauze dressing (SD), ChitoFlex® dressing (CF), QuikClot® ACS؉™ dressing (QC), and CELOX™ dressing (CX). A groin injury with limited vessel access was created in each animal. Subjects were resuscitated with 500 mL of hetastarch. The primary endpoint was 180-min survival. Secondary endpoints included total blood loss in mL/kg, incidence of re-bleeding, survival times among the animals that did not survive for 180 min, failure to achieve initial hemostasis, incidence of recurrent bleeding, time to initial re-bleeding, amount of re-bleeding, and mass of residual hematoma. Results: Survival occurred in 10 of 12 SD animals, 10 of 12 CF animals, 10 of 12 QC animals, and 9 of 12 CX animals. No statistically significant difference was found. Conclusion: In our study of limited-access extremity bleeding, ChitoFlex® performed equally well in mitigating blood loss and promoting survival. The ChitoFlex® dressing is an equally effective alternative to currently available hemostatic agents. However, no agents were superior to standard gauze in our model of limited access. Published by Elsevier Inc.

Research paper thumbnail of Comparison of Celox-A, ChitoFlex, WoundStat, and Combat Gauze Hemostatic Agents Versus Standard Gauze Dressing in Control of Hemorrhage in a Swine Model of Penetrating Trauma

Academic Emergency Medicine, Apr 1, 2011

Objectives: Uncontrolled hemorrhage remains one of the leading causes of trauma deaths and one of... more Objectives: Uncontrolled hemorrhage remains one of the leading causes of trauma deaths and one of the most challenging problems facing emergency medical professionals. Several hemostatic agents have emerged as effective adjuncts in controlling extremity hemorrhage. However, a review of the current literature indicates that none of these agents have proven superior under all conditions and in all wound types. This study compared several hemostatic agents in a lethal penetrating groin wound model where the bleeding site could not be visualized. Methods: A complex groin injury with a small penetrating wound, followed by transection of the femoral vessels and 45 seconds of uncontrolled hemorrhage, was created in 80 swine. The animals were then randomized to five treatment groups (16 animals each). Group 1 was Celox-A (CA), group 2 was combat gauze (CG), group 3 was Chitoflex (CF), group 4 was WoundStat (WS), and group 5 was standard gauze (SG) dressing. Each agent was applied with 5 minutes of manual pressure. Hetastarch (500 mL) was infused over 30 minutes. Hemodynamic parameters were recorded over 180 minutes. Primary endpoints were attainment of initial hemostasis and incidence of rebleeding. Results: Overall, no difference was found among the agents with respect to initial hemostasis, rebleeding, and survival. Localizing effects among the granular agents, with and without delivery mechanisms, revealed that WS performed more poorly in initial hemostasis and survival when compared to CA.

Research paper thumbnail of Review of New Topical Hemostatic Dressings for Combat Casualty Care

Military Medicine, May 1, 2014

This review analyzes the new (2008-2013) hemostatic agents and dressings for enhanced efficacy in... more This review analyzes the new (2008-2013) hemostatic agents and dressings for enhanced efficacy in preclinical studies, and investigates supportive findings among case reports of effectiveness and safety in hospital and prehospital literature. A literature search was conducted using PubMed, National Library of Medicine using key words and phrases. The search revealed a total of 16 articles that fit the criteria established for third-generation hemostatic dressings. There were a total of 9 preclinical, 5 clinical, and 2 prehospital studies evaluated. Evaluation of these third-generation studies reveals that mucoadhesive (chitosan) dressings, particularly Celox Gauze and ChitoGauze, clearly show equal efficacy to Combat Gauze across many dependent variables. Chitosan-based products are ideal prehospital dressings because they are shown to work independently from the physiological clotting mechanisms. Many first-, second-, and third-generation chitosan-based dressings have been in use for years by the United States and other NATO militaries at the point of injury, and during tactical evacuation, in Operation Enduring Freedom and Operation Iraqi Freedom without reported complications or side effects. Based on the reported efficacy and long-term safety of chitosan-based products, increased use of Celox Gauze and ChitoGauze within the Department of Defense and civilian venues merits further consideration and open debate.

Research paper thumbnail of How the Five Principles of High Reliability Organizations Align with the Five Truths of Special Operations

Journal of Special Operations Medicine