Dan Mirski, MD Director TPMRC-Europe 12 SEP 2013 Oslo, Norway CENTCOM AOR (JPMRC) NORTHCOM AOR (GPMRC) EUCOM AOR (TPMRC-E, CASF, LRMC,) AFRICOM AOR (TPMRC-E) UNCLASSIFIED//FOUO UNCLASSIFIED//FOUO This information is furnished on the condition that it will not be released to another nation without specific authority of the Department of the Air Force of the United States , that it will be used for military purposes only, that individual or corporate rights originating in the information, whether patented or not, will be respected, that the recipient will report promptly to the United States any known or suspected compromise, and that the information will be provided substantially the same degree of security afforded it by the Department of Defense of the United States. Also, regardless of any other markings on the document, it will not be downgraded or declassified without written approval of
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Dan Mirski, MD Director TPMRC-Europe
12 SEP 2013 Oslo, Norway
CENTCOM AOR(JPMRC)
NORTHCOM AOR(GPMRC)
EUCOM AOR(TPMRC-E, CASF, LRMC,)
AFRICOM AOR(TPMRC-E)
UNCLASSIFIED//FOUO
UNCLASSIFIED//FOUO
This information is furnished on the condition that it will not be released to another nation without specific authority of the Department of the Air Force of the United States , that it will be used for military purposes only, that individual or corporate rights originating in the information, whether patented or not, will be respected, that the recipient will report promptly to the United States any known or suspected compromise, and that the information will be provided substantially the same degree of security afforded it by the Department of Defense of the United States. Also, regardless of any other markings on the document, it will not be downgraded or declassified without written approval of the originating agency. USAFE N0885-13//20130909
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OutlineUSAF Flight SurgeonOverview of US System Aeromedical
independently associated with improved survival for patients with combat-related traumatic injuries. J Trauma. 2009;66:S69-S76.
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Blood Tx: LIFONew blood over old blood
Previously, the oldest blood in the theater was given first for transfusions should be used before it goes bad.
Fresh blood has been shown to be superior complications of transfusion with "older" units of PRBCs "storage lesion": increase pro-inflammatory factors, acidosis,
increased free hemoglobin, and decreased RBC deformability, 2,3 DPG & ATP
The people most likely to suffer the consequences of complications of "older" units of blood are those requiring a higher dose
In patients requiring massive transfusion , effort made to transfuse fresh units of PRBCs Preferably < 14 days old, but the freshest available nonetheless
Now, LAST IN, FIRST OUT (LIFO) Blood Policy Donation to availability in theater averaging 7 days
1. Spinella PC, Perkins JG, et al. Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries. J Trauma. 2009;66:S69-76.
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Damage Control SurgeryWe now transport patients with “unfinished
surgeries” - open abdomens bleeding stopped via clamping and/or packing.
They are moved to higher levels for more definitive care
Further damage control surgeries done“Final” closure surgery
Eastridge BJ, Mabry RL, Seguin P, Cantrell J, Tops T, Uribe P, Mallett O, Zubko T, Oetjen-Gerdes L, Rasmussen T, Butler FK, Kotwal RS, Holcomb JB, Wade C, Champion H, Lawnick M, Moores L and Blackbourne LH. Death on the battlefield (2001-2011): Implications for the future of combat casualty care. J Trauma. 2012;73:S431-S437,
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Burn ManagementRule of 10's and 6 ml/kg/%BSA burned in thermal injury
burn managementBasically, now we don’t pour in the fluid.Start with an initial amount
Then adjust it up or down up to 25% per hour (not more!) Result = far less incidents of abdominal compartment
syndrome CCATT transported patients with burns up to 98% and they
have survived.
1. Ennis JL, Chung KK, Renz EM, Barillo DJ, Albrecht MC, Jones JA, Blackbourne LH, Cancio LC, Eastridge BJ, Flaherty SF, Dorlac WC, Kelleher KS, Wade CE, Wolf SE, Jenkins DH, Holcomb JB. Joint Theater Trauma System implementation of burn resuscitation guidelines improves outcomes in severely burned military casualties. J Trauma. 2008;64(2):S146-51; discussion 151-2.
2. Markell KW, Renz EM, White CE, Albrecht ME, Blackbourne LH, Park MS, Barillo DA, Chung KK, Kozar RA, Minei JP, Cohn SM, Herndon DN, Cancio LC, Holcomb JB,Wolf SE. Abdominal complications after severe burns. J Am Coll Surg. 2009;208(5):940-7; discussion 947-9.
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Vents: Decreased TVLung protective strategies in ARDS / ICU /
Difficult to Ventilate ptsTidal Volume: 4-6 cc/Kg
Not 10-12 cc/Kg, as priorIdeal BWIncrease PEEP and/or FiO2
Essentially ARDSNetUsed very often by US CCATT
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Other Advances7. Massive transfusion triggersHigher quantities of blood up frontMcLaughlin DF, Niles SE, Salinas J, et al. A predictive model for massive transfusion in combat casualty patients. J Trauma.2008;64:S57-63.
6. PCA, Epidural and nerve blocks We fly these all the time now
Waiver x 10yrs, Official since 2012 Mepivacaine 250 vs 400ml IV bagsKatz J, Cohen L, Schmid R, et al. Postoperative Morphine Use and hyperalgesia are Reduced by Preoperative but not Intraoperative Epidural Anagesia: Implications for Preemptive Analgesia and the Prevention of Central Sensitization. Anesthesiology. 2003;98:1449-1460.
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Lessons Learned (con’t)8. Re-emergence of tourniquets
9. No steroids in blunt spinal cord or TBINo proven benefitWorsen outcomes in patients with severe head
injuryFrequent associated open or contaminated
wounds of battle casualties further complicate steroid administration