: Objective: The purpose of this study was to determine if emergency tourniquet use saved lives. Summary Background Data: Tourniquets have been proposed as lifesaving devices in the current war and are now issued to all soldiers. Few studies, however, describe their actual use in combat casualties. Methods: A prospective survey of injured who required tourniquets was performed over 7 months in 2006 (NCT00517166 at ClinicalTrials.gov). Follow-up averaged 28 days. The study was at a combat support hospital in Baghdad. Among 2838 injured and admitted civilian and military casualties with major limb trauma, 232 (8%) had 428 tourniquets applied on 309 injured limbs. We looked at emergency tourniquet use, and casualties were evaluated for shock (weak or absent radial pulse) and prehospital versus emergency department (ED) tourniquet use. We also looked at those casualties indicated for tourniquets but had none used. We assessed survival rates and limb outcome. Results: There were 31 deaths (13%). Tourniquet use when shock was absent was strongly associated with survival (90% vs. 10%; P less than 0.001). Prehospital tourniquets were applied in 194 patients of which 22 died (11% mortality), whereas 38 patients had ED application of which 9 died (24% mortality; P less than 0.05). The 5 casualties indicated for tourniquets but had none used had a survival rate of 0% versus 87% for those casualties with tourniquets used ( P less than 0.001). Four patients (1.7%) sustained transient nerve palsy at the level of the tourniquet. No amputations resulted solely from tourniquet use. Conclusions: Tourniquet use when shock was absent was strongly associated with saved lives, and prehospital use was also strongly associated with lifesaving. No limbs were lost due to tourniquet use. Education and fielding of prehospital tourniquets in the military environment should continue.

/pdf/survival-with-emergency-tourniquet-use-to-stop-bleeding-in-5e6abz40ib.pdf

Survival with emergency tourniquet use to stop bleeding in major limb trauma.

BACKGROUND: This study was undertaken to determined the differences in injury patterns between soldiers equipped with modern body armor in an urban environment compared with the soldiers of the Vietnam War. METHODS: From July 1998 to March 1999, data were collected for a retrospective analysis on all combat casualties sustained by United States military forces in Mogadishu, Somalia, on October 3 and 4, 1993. This was the largest and most recent urban battle involving United States ground forces since the Vietnam War. RESULTS: There were 125 combat casualties. Casualty distribution was similar to that of Vietnam; 11% died on the battlefield, 3% died after reaching a medical facility, 47% were evacuated, and 39% returned to duty. The incidence of bullet wounds in Somalia was higher than in Vietnam (55% vs. 30%), whereas there were fewer fragment injuries (31% vs. 48%). Blunt injury (12%) and burns (2%) caused the remaining injuries in Somalia. Fatal penetrating injuries in Somalia compared with Vietnam included wounds to the head and face (36% vs. 35%), neck (7% vs. 8%), thorax (14% vs. 39%), abdomen (14% vs. 7%), thoracoabdominal (7% vs. 2%), pelvis (14% vs. 2%), and extremities (7% vs. 7%). No missiles penetrated the solid armor plate protecting the combatants' anterior chests and upper abdomens. Most fatal penetrating injuries were caused by missiles entering through areas not protected by body armor, such as the face, neck, pelvis, and groin. Three patients with penetrating abdominal wounds died from exsanguination, and two of these three died after damage-control procedures. CONCLUSION: The incidence of fatal head wounds was similar to that in Vietnam in spite of modern Kevlar helmets. Body armor reduced the number of fatal penetrating chest injuries. Penetrating wounds to the unprotected face, groin, and pelvis caused significant mortality. These data may be used to design improved body armor.

/pdf/united-states-army-rangers-in-somalia-an-analysis-of-combat-2p4wcw1b1y.pdf

United States Army Rangers in Somalia: an analysis of combat casualties on an urban battlefield.

Advances in prehospital care and trauma resuscitation have enabled the early survival of many injured patients who previously had a high chance of dying at the accident scene or en route to the hospital. The change in the spectrum of injury severity, characterized by high-energy blunt trauma with multiple-organ injury and fractures, and the emergence of semiautomatic handguns with multiple penetrating wounds, present new challenges to all surgeons. In conventional trauma care, definitive control and repair of all injuries may be accomplished in the immediate postinjury setting; however, the physiologic derangements of the massive shock state caused by the aforementioned injury patterns often lead to a fully repaired but dead patient. In response to these catastrophic challenges, the concept of “damage control” as a treatment merely to control but not definitively repair injuries has arisen. This term was originally coined by the United States Navy, in reference to “the capacity of a ship to absorb damage and maintain mission integrity.” 1 In the patient with multiple injuries who is exsanguinating, this has been paraphrased to indicate the sum total of the maneuvers necessary to ensure patient survival above all else. 2

Damage control: collective review.

Since ancient times we have attempted to facilitate hemostasis by application of topical agents. In the last decade, the number of different effective hemostatic agents has increased drastically. In order for the modern surgeon to successfully choose the right agent at the right time, it is essential to understand the mechanism of action, efficacy and possible adverse events as they relate to each agent. In this article we provide a comprehensive review of the most commonly used hemostatic agents, subcategorized as physical agents, absorbable agents, biologic agents, and synthetic agents. We also evaluate novel hemostatic dressings and their application in the current era. Furthermore, wholesale acquisition prices for hospitals in the United States are provided to aid in cost analysis. We conclude with an expert opinion on which agent to use under different scenarios.

A comprehensive review of topical hemostatic agents: efficacy and recommendations for use.

Background: Primary (1°) abdominal compartment syndrome (ACS) is a known complication of damage control. Recently secondary (2°) ACS has been reported in patients without abdominal injury who require aggressive resuscitation. The purpose of this study was to compare the epidemiology of 1° and 2° ACS and develop early prediction models in a high-risk cohort who were treated in a similar fashion. Methods: Major torso trauma patients underwent standardized resuscitation and had prospective data collected including occurrence of ACS, demographics, ISS, urinary bladder pressure, gastric tonometry (GAP CO2 = gastric regional CO 2 minus end tidal CO 2 ), laboratory, respiratory, and hemodynamic data. With 1° and 2° ACS as endpoints, variables were tested by uni- and multivariate logistic analysis (MLA). Results: From 188 study patients during the 44-month period, 26 (14%) developed ACS-11 (6%) were 1° ACS and IS (8%) 2° ACS. 1° and 2° ACS had similar demographics, shock, and injury severity. Significant univariate differences included: time to decompression from ICU admit (600 ± 112 vs. 360 ± 48 min), Emergency Department (ED) crystalloid (4 ± 1 vs. 7 ± 1 L), preICU crystalloid (8 ± 1 vs. 12 ± 1L), ED blood administration (2 ± 1 vs. 6 ± 1 U), GAP CO2 (24 ± 3 vs. 36 ± 3 mmHg), requiring pelvic embolization (9 vs. 47%), and emergency operation (82% vs. 40%). Early predictors identified by MLA of 1° ACS included hemoglobin concentration, GAP CO2 , temperature, and base deficit; and for 2° ACS they included crystalloid, urinary output, and GAP CO2 . The areas under the receiver-operator characteristic curves calculated upon ICU admission are 1° = 0.977 and 2° = 0.983. 1° and 2° ACS patients had similar poor outcomes compared with nonACS patients including ventilator days (1° = 13 ± 3 vs. 2° = 14 ± 3 vs. nonACS = 8 ± 2), multiple organ failure (55% vs. 53% vs. 12%), and mortality (64% vs. 53% vs. 17%). Conclusion: 1° and 2° ACS have similar demographics, injury severity, time to decompression from hospital admit, and bad outcome. 2° ACS is an earlier ICU event preceded by more crystalloid administration. With appropriate monitoring both could be accurately predicted upon ICU admission.

Both primary and secondary abdominal compartment syndrome can be predicted early and are harbingers of multiple organ failure.

Background
Morgagni hernias are a very rare form of diaphragmatic hernias. No robust studies have been performed to show the true natural history of this disease process. This study aimed to summarize clinically relevant data with respect to Morgagni hernias in adults. These data should help surgeons workup, diagnose, and treat Morgagni hernias in adult patients.

Presentation and management of Morgagni hernias in adults : a review of 298 cases

Objective To determine if a dry fibrin sealant dressing (DFSD) will provide superior hemostasis when compared with regular gauze in a ballistic injury animal model. Design A nonsurvival randomized goat study. Setting A federal biomedical research institute. Subjects Eighteen anesthetized Angora goats. Interventions Uncontrolled hemorrhage was induced by a complex ballistic extremity injury. Control of hemorrhage was achieved by applying and holding pressure with the DFSD or regular gauze for 2 minutes. The dressings were left in place for 1 hour. Main Outcome Measures Total blood loss, mean arterial pressure, ballistic injury, and mortality were recorded after 1 hour. Results The injuries were equivalent for the 2 groups. No animal mortality was seen. After 1 hour, the mean(±SEM) blood loss was 124±64 mL in the DFSD-treated group and 377±64 mL in the gauze dressings–treated group ( P =.01). Twenty minutes after injury, the mean arterial pressure was 95.0 mm Hg (±SEM, ±4.7 mm Hg) in the DFSD-treated group and 70.0±5.0 mm Hg in the gauze dressings–treated group. The difference persisted for the remainder of the study ( P =.01). Conclusion The DFSD was superior to gauze in decreasing blood loss and maintaining blood pressure while retaining the simplicity of standard dressing application.

https://jamanetwork.com/journals/jamasurgery/articlepdf/211466/SOA6203.pdf

Efficacy of a Dry Fibrin Sealant Dressing for Hemorrhage Control After Ballistic Injury

Biliary dyskinesia: a study of more than 200 patients and review of the literature

Implications of new dry fibrin sealant technology for trauma surgery

Readers are invited to contact Greg S. Loeben in writing at Midwestern University, Glendale Campus, Bioethics Program, 19555 N. 59th Ave., Glendale, AZ 85308 (gloebe@midwestern.edu) regarding books they would like to see reviewed or books they are interested in reviewing.

Stephen P. Hetz

Papers

Presentation and management of Morgagni hernias in adults : a review of 298 cases

Efficacy of a Dry Fibrin Sealant Dressing for Hemorrhage Control After Ballistic Injury

Biliary dyskinesia: a study of more than 200 patients and review of the literature

Implications of new dry fibrin sealant technology for trauma surgery

War Surgery in Afghanistan and Iraq: A Series of Cases, 2003–2007