J Trauma
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Historical Article
Now and then: combat casualty care policies for Operation Iraqi Freedom and Operation Enduring Freedom compared with those of Vietnam.
Between December 2004 and June 2007, 13 key Operation Iraqi Freedom/Operation Enduring Freedom combat casualty care policies were published to inform medical practice in the combat theater of operations. Published policies were authored by the 44th Medical Command (1), the Office of The Army Surgeon General (11), and the Office of the Assistant Secretary of Defense (Health Affairs) (1). ⋯ Common to both wartime eras was the recognition that the presence of a medical research team in theater was a critical element to ensure accurate data capture for subsequent analysis, to document lessons learned, and to study the impact of new wounding mechanisms, whether it be the Pungi sticks and mines of Vietnam or the types of explosions specific to Operation Iraqi Freedom/Operation Enduring Freedom. It is important to recognize that both then and now, medical practice has been a reflection of the current state of medical practice, and that in both conflicts military medical personnel have been equally devoted to saving lives of combat casualties.
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Fresh whole blood (FrWB) is routinely used in the resuscitation of combat casualties in Operation Iraqi Freedom and Operation Enduring Freedom. However, studies have shown high rates (20%-40%) of transfusion-associated microchimerism (TA-MC) in civilian trauma patients receiving allogenic red blood cell (RBC) transfusions. We explored the incidence of TA-MC in combat casualties receiving FrWB compared with patients receiving standard stored RBC transfusions. ⋯ Although these preliminary data do not demonstrate a significantly increased rate of TA-MC in FrWB or apheresis platelets recipients compared with RBC recipients, the overall 45% (10 of 22) rate of TA-MC in transfused soldiers warrants further study to ascertain possible clinical consequences such as graft-versus-host or autoimmune disease syndromes.
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Comparative Study
Incidence of adverse events during prehospital rapid sequence intubation: a review of one year on the London Helicopter Emergency Medical Service.
To establish the incidence of hypoxemia and hypotension during prehospital rapid sequence intubation (RSI) in trauma patients attended by the London Helicopter Emergency Medical Service (HEMS) and to compare it with historical control data from published studies of both hospital and prehospital RSI. ⋯ Rates of hypoxemia and hypotension during prehospital RSI performed by London HEMS are relatively low. They are less than that found in previous studies of prehospital RSI and are similar to those reported in studies of in-hospital emergency RSI undertaken in the emergency department or ward setting. We therefore conclude that prehospital RSI has an acceptably low complication rate when performed by appropriately trained personnel.
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The Division of Research at JCAHO developed a taxonomy (common terminology and classification schema) to promote consistency in reporting and facilitate root cause analysis. We undertook a review of trauma management errors at our institution with maximal impact (death). The analysis was based on the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) taxonomy. ⋯ Management errors in the basics of trauma care continue even in established trauma centers, despite guidelines, protocols, and continuous performance improvement. Standardized reporting such as the taxonomy may result in progressive collection of patient safety data and lead to innovations to minimize these errors.
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Comparative Study
Intracranial pressure monitoring in brain-injured patients is associated with worsening of survival.
The Brain Trauma Foundation (BTF) recommends intracranial pressure (ICP) monitoring in traumatic brain injury (TBI) patients with Glasgow Coma Scale (GCS) of 8 or less, and an abnormal brain computed tomography. However, benefits of ICP monitoring have not been documented. We hypothesized that BTF criteria for ICP monitoring in blunt TBI do not identify patients who are likely to benefit from it. ⋯ ICP monitoring in accordance with current BTF criteria is associated with worsening of survival in TBI patients. A prospective randomized controlled trial of ICP-guided therapy is needed. Until then, the use of ICP monitoring should not be used as a quality benchmark.