Journal of special operations medicine : a peer reviewed journal for SOF medical professionals
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No data have been published on the use of ketamine at the point of injury in combat. ⋯ In this small, retrospective sample of combat casualties, ketamine appeared to be a safe and effective battlefield analgesic.
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This report reviews the recent literature on fluid resuscitation from hemorrhagic shock and considers the applicability of this evidence for use in resuscitation of combat casualties in the prehospital Tactical Combat Casualty Care (TCCC) environment. A number of changes to the TCCC Guidelines are incorporated: (1) dried plasma (DP) is added as an option when other blood components or whole blood are not available; (2) the wording is clarified to emphasize that Hextend is a less desirable option than whole blood, blood components, or DP and should be used only when these preferred options are not available; (3) the use of blood products in certain Tactical Field Care (TFC) settings where this option might be feasible (ships, mounted patrols) is discussed; (4) 1:1:1 damage control resuscitation (DCR) is preferred to 1:1 DCR when platelets are available as well as plasma and red cells; and (5) the 30-minute wait between increments of resuscitation fluid administered to achieve clinical improvement or target blood pressure (BP) has been eliminated. ⋯ Maintained as recommendations are an emphasis on hypotensive resuscitation in order to minimize (1) interference with the body's hemostatic response and (2) the risk of complications of overresuscitation. Hextend is retained as the preferred option over crystalloids when blood products are not available because of its smaller volume and the potential for long evacuations in the military setting.
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Randomized Controlled Trial Comparative Study
Intra-articular Morphine versus Lidocaine for Acute Knee Pain.
The authors conducted an unfunded randomized controlled trial approved by the Brooke Army Medical Center (BAMC) Institutional Review Board (IRB) to determine the possible efficacy of intra-articular morphine for pain in acute knee injuries. ⋯ Further investigation with a larger sample is required to explore whether these results are statistically significant and the possible superiority of intra-articular morphine to lidocaine for acute knee pain.
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Current guidelines for mass-casualty triage do not explicitly use information about resource availability. Even though this limitation has been widely recognized, how it should be addressed remains largely unexplored. The authors present a novel framework developed using operations research methods to account for resource limitations when determining priorities for transportation of critically injured patients. To illustrate how this framework can be used, they also develop two specific example methods, named ReSTART and Simple-ReSTART, both of which extend the widely adopted triage protocol Simple Triage and Rapid Treatment (START) by using a simple calculation to determine priorities based on the relative scarcity of transportation resources. ⋯ Taking resource limitations into account in mass-casualty situations, triage has the potential to increase the expected number of survivors. Further validation is required before field implementation; however, the framework proposed in here can serve as the foundation for future work in this area.
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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. ⋯ 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 chitosan-based 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., Crewe, UK; http://www.celoxmedical.com/usa/products /celox-gauze/) and ChitoGauze® (HemCon Medical Technologies, Portland, OR, USA; http://www.hemcon.com/) to the TCCC Guidelines.