Blood Loss in Soldiers (original) (raw)
Trauma and Military Applications of Blood Substitutes
Artificial Cells, Blood Substitutes, and Biotechnology, 1994
This docume.;t has been approved for public 2bDE-CLASSFINC-ATION I DO , W release, distribution is unlimited. 4. PERFORMNO ORGANIZATIONRE(-S. MONITORING ORGANIZATION REPORT NUMBER(S) 6a. NAME OF PERFORMING ORGANIZATION 6b OFFICE SYMBOL.-7a-NAME OF MONITORING ORGANIZATION Division of filitary Trauma. (itappliable)
2008
Medical care in modern warfare is challenged by the use of high-explosive weapons that can induce mass casualties. In the current conflicts, improvements in body armour, the use of tourniquets and hemostatic dressings and in most cases, rapid evacuation times has resulted in higher survival rates than seen in prior wars. A major medical advance in the current conflicts is the initiation of damage control resuscitation for the treatment of severely injured Soldiers, particularly those who require massive transfusion and have dysfunction of their blood clotting system and the highest risk of dying. Recent retrospective analysis of traumatic injuries has revealed that patients who received plasma or a plasma to RBC ratio close to 1:1, had improved survival compared to patients who received standard transfusion therapy of plasma to RBC ratios of 1:4 or greater. As further analysis of the benefits of plasma are realized, research efforts in the laboratory are investigating and characterizing a freeze-dried plasma compared to standard fresh frozen plasma, so the benefits of this blood product can be delivered to far forward locations for the early treatment of severely injured Soldiers. 14. ABSTRACT 15. SUBJECT TERMS 16. SECURITY CLASSIFICATION OF: 17. LIMITATION OF ABSTRACT UU 18. NUMBER OF PAGES 7 19a. NAME OF RESPONSIBLE PERSON a. REPORT unclassified b. ABSTRACT unclassified c. THIS PAGE unclassified Standard Form 298 (Rev. 8-98) Prescribed by ANSI Std Z39-18
Constant challenges and evolution of US military transfusion medicine and blood operations in combat
Transfusion, 2012
BACKGROUND: Blood operations are constrained by many limitations in combat settings. As a result there are many challenges that require innovative solutions. STUDY DESIGN AND METHODS: This is a descriptive overview of blood product usage and transfusion medicine adaptations that have been employed by the US military to support combat operations in Iraq and Afghanistan between November 2001 and December 2010. RESULTS: Transfusion medicine challenges have included the need for rapid transport of large quantities of blood products from the United States to Iraq and Afghanistan, risks and appropriate countermeasures associated with blood products collected in the theater of operations, availability of fresh-frozen plasma at forward surgical facilities, need for platelets (PLTs) in combat, and the need to support constant and evolving changes in transfusion and resuscitation protocols. A decrease in the storage age of red blood cells (RBCs) transfused to combat casualties has been achieved. There has been an increase in the ratio of plasma and PLTs to RBCs transfused, increased availability of plasma and apheresis PLTs to facilitate this approach, and a continuous effort to improve the safety of using fresh whole blood and apheresis PLTs collected in combat. A number of clinical practice guidelines are in place to address these processes. CONCLUSION: This multidisciplinary approach has successfully addressed many complicated and challenging issues regarding blood operations and transfusion practices for combat casualties. ABBREVIATIONS: ASWBPL = Armed Services Whole Blood Processing Laboratory; CENTCOM = Central Command; MTF(s) = medical treatment facility (-ies); WWI (-II) = World War I (II).
Transfusion, 2013
BACKGROUND: Bleeding is a major cause of death in combat settings, and combat casualties in shock may benefit from fresh whole blood (FWB) transfusion. "Buddy transfusion" is a well-known lifesaving intervention, but little is known about donor combat safety aspects immediately after blood donation. The objectives of this study were to explore the effects of donation of 1 unit of blood on physical and combat-related performance among active duty soldiers. We also investigated the feasibility of a short training program to teach nonmedics buddy transfusion. STUDY DESIGN AND METHODS: Twenty-five fit male soldiers from a special forces unit were divided into three groups and tested on 1) a Bruce protocol treadmill stress test, push-ups, and pull-ups; 2) a 50-round rapid pistol shooting test; and 3) an uphill hiking exercise carrying a 20-kg backpack. After baseline testing, the soldiers performed the tests again (2-6 min) after donating 450 mL of blood. The training program included blood collection and reinfusion procedures and we measured success rate of venipuncture, time for blood collection, and success in placing sternal intraosseous needle and reinfusing 1 unit of autologous blood. RESULTS: We did not find any significant decrease in performance either in physical or in shooting performance after donating blood. Nonmedic soldiers had a 100% success rate in blood collection and also infusion on fellow soldiers after a short introduction to the procedures. CONCLUSION: This study supports the fact that buddy transfusion may be feasible for healthy well-trained soldiers and does not decrease donor combat performance under ideal circumstances. ABBREVIATIONS: DCR = damage control resuscitation; FWB = fresh whole blood; HRmax = maximum heart rate.
Whole blood transfusion closest to the point-of-injury during French remote military operations
The journal of trauma and acute care surgery, 2017
To improve the survival of combat casualties, interest in the earliest resort to whole blood (WB) transfusion on the battlefield has been emphasized. Providing volume, coagulation factors, plasma, and oxygenation capacity, WB appears actually as an ideal product severe trauma management. Whole blood can be collected in advance and stored for subsequent use, or can be drawn directly on the battlefield, once a soldier is wounded, from an uninjured companion and immediately transfused.Such concepts require a great control of risks at each step, especially regarding ABO mismatches, and transfusion-transmitted diseases. We present here the "warm and fresh" WB field transfusion program implemented among the French armed forces. We focus on the followed strategies to make it applicable on the battlefield, even during special operations and remote settings, and safe for recipients as well as for donors.
Analysis of the Causes of Death of Casualties in Field Military Setting
Military Medicine, 2012
Objective: We assessed the causes of death of military casualties in order to determine the characteristics of injury and to determine how survivability can be improved. Methods: A retrospective review of the trauma registry of the Israel Defense Forces was conducted. The causes of death were determined. Casualties that were found alive but died later at any level of care were included. Results: Information about casualties that was recorded during the years 2002-2009 was reviewed. Eighty-one fatalities were included in the analysis. Fifty-one (63%) fatalities were caused by gunshot wounds. Analysis of the data regarding the cause of death revealed that 66 (81.5%) of the casualties died because of hemorrhage and 25 (30.9%) because of head trauma. Of the casualties that died of hemorrhage, 12 (18.2%) had neck or limbs potentially compressible hemorrhage. All fatalities from hemorrhage died before arriving at a medical facility. Conclusion: Torso noncompressible hemorrhage was found to be the main cause of death among the casualties investigated. Potentially compressible hemorrhage and head injury are significant too. Research and development of means to treat hemorrhage and emphasis on distribution of means to stop hemorrhage and on training may improve outcome of potentially compressible hemorrhage.
Fresh Whole Blood Transfusion: A Controversial Military Practice
The Journal of Trauma: Injury, Infection, and Critical Care, 2006
The transfusion of fresh whole blood (FWB) for trauma-induced coagulopathy is unusual in civilian practice. However, US military physicians have used FWB in every combat operation since the practice was introduced in World War I and continue to do so during current military operations. We discuss our review of all blood products administered to US military casualties in Operation Iraqi Freedom (OIF) between March and December 2003. FWB transfusions were most frequent when demands for massive transfusions wiped out existing blood supplies. FWB patients had the highest blood product requirements; however, mortality did not differ significantly between FWB and non-FWB patients overall or for massively transfused patients. We review the current military practice of FWB transfusion in combat theaters and conclude that FWB transfusion is convenient, safe, and effective in certain military situations.
Transfusion practice in military trauma
Transfusion Medicine, 2008
Modern warfare causes severe injuries, and despite rapid transportation to theater regional trauma centers, casualties frequently arrive coagulopathic and in shock. Conventional resuscitation beginning with crystalloid fluids to treat shock causes further dilutional coagulopathy and increased hemorrhagic loss of platelets and coagulation factors. Established coagulopathy was difficult to reverse in the face of uncontrolled hemorrhage. Because many of the casualties met conventional plasma and platelet transfusion criteria on admission, thawed AB plasma was prepositioned in the trauma receiving area and used in a 1:1 ratio with red cells for resuscitation and fresh whole blood was used as a source of platelets. Retrospective assessments of this 1:1 therapy strongly suggested that it resulted in improved hemostasis, shorter ventilator times, and improved survival. Component therapy, when available, appears to be as effective as fresh whole blood. In field emergencies, fresh whole blood can be lifesaving.
The Journal of Trauma: Injury, Infection, and Critical Care, 2010
Background: Timely initiation of a massive transfusion (MT) protocol is associated with improved survival and reduced transfusion for patients requiring MT; however, a priori identification of this population is difficult. The objective of this study was to compare the results of an MT prediction model and actual MT incidence in combat casualties. Methods: We performed a retrospective review of the Joint Theater Trauma Registry transfusion database for all US service personnel injured in combat during overseas contingency operations who received at least 1 unit of blood. Systolic blood pressure at the time of admission, heart rate, hemoglobin, international normalized ratio, and base deficit were used in a previously developed prediction model for MT. Results: Casualties (n ϭ 1124) were identified who had received at least 1 unit of blood and had all data points. Of these patients, 420 patients (37%) received an MT. Subjects presenting with any two of four possible variables (heart rate Ͼ110, systolic blood pressure Ͻ110 mm Hg, base deficit ՅϪ6, and hemoglobin Ͻ11) had a 54% incidence of MT with a model sensitivity of 69%. Patients predicted but not observed to receive an MT had earlier time of death and an increased incidence of head injuries compared with those predicted and observed to receive an MT. Patients not predicted but observed to receive an MT had increased chest, abdominal, and extremity injuries than those neither predicted nor observed to receive an MT. Conclusion: The decision to implement an MT seems to rely heavily on clinical evaluation of severity of abdominal and extremity injury rather than physiologic derangement. Using a model based on the physiologic parameters-a more objective measure-may decrease mortality in combat casualties.
Fibrinogen Concentrate in the Special Operations Forces Environment
Military Medicine
Introduction: Hemorrhage is the most common cause of death among Special Operations Force (SOF) soldiers. Bringing remote damage control resuscitation into the far-forward combat environment is logistically challenging, as it requires blood products that generally require a robust cold chain. Alternatively, lyophilized products such as fibrinogen concentrate, which does not require thawing or blood group compatibility testing before use, might be advantageous in damage control resuscitation in the battlefield. In this report, we review the evidence for the use of fibrinogen concentrate in the Canadian SOF environment. Materials and Methods: The literature on the use of fibrinogen concentrate in the trauma setting was reviewed by Canadian Forces Services Working Group, in three separate meetings. Multiple stakeholders were consulted to obtain authoritative perspectives from subject matter experts on the use of fibrinogen concentrate in the Canadian SOF environment. We also conducted a comparison review of fibrinogen content, pathogen risk, shelf life, and methods required for use for fresh frozen plasma, cryoprecipitate, and fibrinogen concentrate relevant to their application in the far-forward combat environment. Results: Indications and a protocol for the use of fibrinogen as an adjunct to fresh whole blood were formulated based on a literature review and clinical expert opinion. Alternative strategies and other lyophilized blood products were considered before selecting fibrinogen concentrate as the lyophilized blood product of choice. Fibrinogen concentrate is an ABO-universal blood product with an excellent safety profile. Training was conducted by subject matter experts within civilian trauma centers and at military training facilities. The clinical efficacy and safety were confirmed by monitoring the use of fibrinogen concentrate in deployed combat settings. Conclusion: Fibrinogen concentrate is a useful adjunct to remote damage control resuscitation in the SOF environment. Fibrinogen concentrate was found to be robust for transport into the SOF environment and is widely accepted among SOF operators and medics.
Vascular Injury in the Wars in Iraq and Afghanistan
Blood vessel trauma leading to hemorrhage or ischemia represents a significant cause of morbidity and mortality following injury. The objective of this study is to characterize the epidemiology of vascular injury in the wars in Iraq and Afghanistan and delineate anatomic patterns of injury, and the management categories of repair and ligation. Methods: The Joint Theater Trauma Registry was queried (2002-2009) for vascular injury in US troops and specific (Group 1) and operative (Group 2) groups defined. Group numbers were divided by battle related injuries (non-return to duty) to establish injury rates. Results: Group 1 included 1,570 Troops injured in Iraq (OIF) (n=1,390) and Afghanistan (OEF) (n=180). Mechanism included explosive (73%), gunshot (27%) and other (<1%) with explosive more common in OIF than OEF (p<0.05). During this period, 13,076 battle related injuries occurred resulting in a specific rate of 12% (1,570/13,076) which was higher in OIF than OEF (12.5% vs. 9% r...
Journal of special operations medicine : a peer reviewed journal for SOF medical professionals, 2010
The leading cause of death on the battlefield is uncontrolled hemorrhage. Non-compressible (truncal) hemorrhage is the cause over two thirds of these deaths. This makes truncal hemorrhage the leading cause of potentially survivable death on the battlefield. Over one third of the casualties who arrive at the emergency department (ED) or combat surgical hospital (CSH) in need of a blood transfusion are already suffering from acute traumatic coagulopathy which is associated with an 80% mortality. Early aggressive treatment and prevention of this coagulopathy through hemostatic resuscitation has been shown to increase survival. Hemostatic resuscitation involves the very early use of blood and blood products as primary resuscitation fluids to both treat intrinsic acute traumatic coagulopathy and prevent the development of dilutional coagulopathy. Few, if any, of the products used in hemostatic resuscitation are currently available to the Special Operations Forces (SOF) medic. Warm fresh ...
Fresh whole blood transfusion capability for Special Operations Forces
Canadian journal of surgery. Journal canadien de chirurgie, 2015
Fresh whole blood (FWB) transfusion is an option for providing volume and oxygen carrying capacity to bleeding Special Operations soldiers who are injured in an austere environment and who are far from a regular blood bank. Retrospective data from recent conflicts in Iraq and Afghanistan show an association between the use of FWB and survival. We reviewed the literature to document the issues surrounding FWB transfusion to Special Operations soldiers in the austere environment and surveyed the literature regarding best practice guidelines for and patient outcomes after FWB transfusions. Most literature regarding FWB transfusion is retrospective or historical. There is limited prospective evidence currently to change transfusion practice in tertiary care facilities, but FWB remains an option in the austere setting.