Summer - United States Special Operations Command

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of patients become coagulopathic much earlier for reasonsthat are at present not well delineated. That fact,coupled with the hemorrhage due to penetrating traumamay lead to a disproportionate loss of clotting factors,inactivation of normal coagulation due to acidosis andhypothermia, and inactivity of factors due to storage inbanked blood and blood components. Consequently,in non-compressible hemorrhage on the battlefield, inan otherwise young and healthy population, there maybe a role for early augmentation of the coagulation cascade.As previously noted, the proteolytic enzymes ofthe coagulation cascade function poorly at pH below7.2. Acidosis slows the rate of thrombin generation,while hypothermia delays the onset of thrombin generation.Biologically plausible arguments can be madefor optimizing and augmenting the coagulation pathwaysand processes before significant hemorrhage occursand shock develops as will be discussed.While we have for the most part solved thechallenge of extremity injury with the use of tourniquets,pressure, and wound packing, the developmentsof new types of hemostatic agents in the form of a pad,packing sponge, or gel have provided adjuncts forcompressible and accessible wounds. The current challengein the field for the medic is the non-compressibleand non-accessible wounds, primarily in theabdomen and pelvis in the absence of immediate surgicalassets. Because of this, the use of non-surgicalsolutions needs to be aggressively considered. Thiswould include the use of Factor VIIa, along with adjunctssuch as calcium and sodium bicarbonate to optimizethe biological activity of this potentiallylifesaving modality. Factor VIIa works by activatingthrough thrombin and various feedback loops both theintrinsic and extrinsic coagulation pathways. The desiredendpoint is assistance in the formation of a thrombusat the site of injury in an otherwise inaccessiblelocation such as solid organs (liver, spleen, and kidney),large vessels, and pelvic structures. This mightbe thought of as mobilizing a damage control party tothe site of injury in our ship analogy. Because of thetime involved, this must be considered for administrationrelatively early if severe hemorrhage is suspected.Delays awaiting conclusive evidence of Class III/IVshock may prove insurmountable. Interestingly, thereis some evidence that thrombus created with rVIIa administrationmay be more resistant to lysis and breakdownwith reperfusion.Correcting coagulapathies will also be assistedby administering the proper blood products, and althoughFWB and FFP are specifically advocated in thisarticle due to their natural contributions, they will beaddressed in Part Two, complete with all other fluidchoices. In addition to resuscitation, prolonged carerequires an exceptional skill set. Tracheotomies, fasciotomies,blood transfusions, anesthesia, and primaryand delayed closure, all play an important role here.These are advanced skills and as such require propersustainment. Nursing skills also have a huge importancein critical care and without them none of theabove would be successful. Competence in aseptictechnique, antibiotic therapy, labs for the monitoringof endpoints, input and output, and basic nursing careincluding patient hygiene need to be appreciated.Other concerns requiring attention are pre and post surgicalskills, wound care, nutrition, rehabilitation, andeven logistical needs. This skill set is now rarely exercised,except in the schoolhouse during records andreports, but is essential in the austere scenario.The authors hope that Part One provides afoundation in general knowledge of DCR for the SFmedic; Part Two will identify options for measuringshock and recommend relative endpoints to serve asgoals in resuscitation. Additionally we will proposenot only the special equipment required, but the minimalequipment needed in care, and identify the criticalcare and nursing skills required to support DCR in ourenvironment.REFERENCES1. BG Yeheskel Levy. (2007). Lecture. Advanced TechnologyApplications for Combat Casualty Care Conference.2. Holcomb J. (2007). Damage control surgery. Journal ofTrauma; 62:S36-S37.3. Blackbourne L, McMullin N, Eastridge B, Baskin T, HolcombJ. (2007). Aggressive proactive combat damagecontrol surgery. AMEDD Journal; January-March.4. Kaplan L, Bailey H. (2007). Ongoing resuscitation endpointsand strategies; Trauma;Emergency Resuscitation Vol1. Inpharma Healthcare.5. Blackbourne L. (2008). Combat damage control surgery.Critical Care Medicine; 36,7:S304-S310.6. Hirshberg A, Mattox K (2006). Top Knife, The 3-D TraumaSurgeon, tfm Publishing Ltd, p. 5-17.20Journal of Special Operations Medicine Volume 9, Edition 3 / Summer 09
7. Ted Westmoreland. (2006). Attributed quote.8. Anjaria D, Mohr A, Deitch D. (2008). Haemorrhagic shocktherapy. Informa Healthcare.9. Hirshberg A, Mattox K (2006). Top Knife. Stop That Bleeding,tfm Publishing Ltd, p. 19-34.10. Kragh J, Walters T, Baer D, et al. (2008). Practical use ofemergency tourniquets to stop bleeding in major limb trauma.Journal of Trauma;64:S38-S50.11. Beekley A. (2008). Damage control resuscitation: A sensibleapproach to the exsanguinating surgical patient. CriticalCare Medicine;36:S267-S274.12. Arthurs Z, Cuadrado D, Beekley A, et al. (2006). The impactof hypothermia on trauma care at the 31st combat supporthospital. The American Journal of Surgery; 191:610-614.13. Blackbourne L, Gratwohl K, et al. (2007). Optimizing transportof postoperative damage control patients in the combatzone. AMEDD Journal; January-March.14 Krishna G, Sleigh J, Rahman H. (1998). Physiological predictorsof death in exsanguinating trauma patients undergoingconventional trauma surgery. Aust NZ Surg; 68:826-829.15. Jurkovich G, Greiser W, et al. (1987). Hypothermia intrauma victims: An ominous predictor of survival. Journal ofTrauma; 1019-24.16. Pend R, Bongard F. (1999). Hypothermia in trauma patients.J Am Coll Surg; 188:685-96.17. Hoffman M. (2004). The cellular basis of traumatic bleeding.Mil Med; 169,12:000.18. MacCleod J. (2008). Trauma and coagulapathy: A new paradigmto consider. Arch of Surgery; 143(8):797-801.COL Gregory Risk is an Emergency Physician/Flight Surgeon currently assigned to USASOC. He completed SFQC asan 18D in 1982 and was assigned to 7th SFG. He graduated from the Indiana University School of Medicine in 1993 andcompleted emergency medicine residency at Methodist Hospital in 1996. COL Risk was previously assigned as AsstDean, Joint Special Operations Medical Training Center.Michael Hetzler has served as a Special Forces Medic for over 15 years in both 1st Special Forces Group and USASOC.Damage Control Resuscitation for the Special Forces Medic:Simplifying and Improving Prolonged Trauma Care: Part One21
Page 1 and 2: Volume 9, Edition 3 / Summer 09 Jou
Page 3 and 4: An 18D deworms a camel during a “
Page 5 and 6: Field Evaluation and Management of
Page 7 and 8: The circumferential anchoring strip
Page 9 and 10: In doing so, all the skin is closed
Page 11 and 12: NATO SOF Transformation and theDeve
Page 13 and 14: current and future operations, thes
Page 15 and 16: sion of a physician, and limited pr
Page 17 and 18: REFERENCES1. James L. Jones, “A b
Page 19 and 20: This article is the first of two me
Page 21 and 22: Figure 4 : A Special Forces medic c
Page 23: exposure. Conversely, the customary
Page 27 and 28: first three days of injury, althoug
Page 29 and 30: 9. Markgraf CG, Clifton GL, Moody M
Page 31 and 32: the only sign of OCS may be elevate
Page 33 and 34: E. The canthotomy allows for additi
Page 35 and 36: 33. Rosdeutscher, J.D. and Stradelm
Page 37 and 38: Tinnitus, a Military Epidemic:Is Hy
Page 39 and 40: The development of chronic NIHL pro
Page 41 and 42: supplied by diffusion. During expos
Page 43 and 44: similar to those of other authors,
Page 45 and 46: promising effect on tinnitus. Howev
Page 47 and 48: ADDITIONAL REFERENCESHoffmann, G; B
Page 49 and 50: et al. demonstrated that both right
Page 51 and 52: TYPICAL CHEST RADIOGRAPH FINDINGS I
Page 53 and 54: 11. Norsk P, Bonde-Petersen F, Warb
Page 55 and 56: ABSTRACTS FROM CURRENT LITERATUREMa
Page 57 and 58: tourniquet times are less than 6 ho
Page 59 and 60: tal from July 1999 to June 2002. In
Page 61 and 62: Operation Sadbhavana: Winning Heart
Page 63 and 64: CENTRAL RETINAL VEIN OCCLUSION IN A
Page 65 and 66: of the X chromosome. Notable is tha
Page 67 and 68: AUTHORS*75th Ranger Regiment6420 Da
Page 69 and 70: Casualties presenting in overt shoc
Page 71 and 72: PSYCHOLOGICAL RESILIENCE AND POSTDE
Page 73 and 74: spondents without PTSD (M = 4.6, SD
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patients, whereas the mean score of
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29. Whealin JM, Ruzek JI, Southwick
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average, time between return from d
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ing functioning in both PTSD (Zatzi
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Editorial Comment on “Psychologic
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Blackburn’s HeadhuntersPhilip Har
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The Battle of Mogadishu:Firsthand A
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Task Force Ranger encountered enemy
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Peter J. Benson, MDCOL, USACommand
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Numerous military and civilian gove
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Anthony M. Griffay, MDCAPT, USNComm
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This is a great read that speaks di
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and twenty-eight. Rabies immune glo
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Rhett Wallace MD FAAFPLTC MC SFS DM
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LTC Craig A. Myatt, Ph.D., HQ USSOC
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LTC Bill Bosworth, DVM, USSOCOM Vet
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Europe, Mideast, Africa and SWAU.S.
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SOF and SOF Medicine Book ListWe ha
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TITLE AUTHOR ISBNCohesion, the Key
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TITLE AUTHOR ISBNI Acted from Princ
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TITLE AUTHOR ISBNRats, Lice, & Hist
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TITLE AUTHOR ISBNThe Healer’s Roa
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TITLE AUTHOR ISBNGuerilla warfare N
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TITLEAUTHORBlack Eagles(Fiction)Bla
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TITLE(Good section on Merrill’s M
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GENERAL REFERENCESALERTS & THREATSB
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Aviation Medicine Resources: http:/
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LABORATORYClinical Lab Science Reso
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A 11 year old boy whose tibia conti
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Meet Your JSOM StaffEXECUTIVE EDITO
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Special Forces Aidman's PledgeAs a
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