By Brenda L. Mooney
BOSTON — In yet another example of how battlefield medicine has altered civilian healthcare practice, damage-control resuscitation (DCR) now is being widely used in trauma centers across the United States.
A survey of trauma medical directors (TMDs) at 245 centers has found that DCR practices that originated in military settings have been adapted in many civilian hospitals across the United States. Results were published recently in the journal Surgery.1
The majority of the TMDs responding to the survey, 67.8%, reported routine use of a blood product ratio of 1:1:1 packed red blood cells, frozen fresh plasma, platelets. Usage of this ratio, which emulates the natural ratio of components in whole blood, has been shown to increase patient survival rates and originated in military settings where whole blood is typically more easily obtainable.
Furthermore, more than 95% of the respondents said their trauma centers had adopted a written massive transfusion protocol directly related to advances in military trauma care. Recently, the Institute of Medicine (IoM) established an ad hoc committee, intended to understand the “military trauma care’s learning health system and its translation to the civilian sector.”
“Historically, many improvements in trauma care have been observed during war and innovations made on the battlefield due to the large and concentrated number of severely-injured patients,” explained co-author Col. Lorne Blackbourne, former commander of the U.S. Army Institute of Surgical Research. “Historically, improvements in operative trauma care have been driven by war and innovations on the battlefield. The objective of this work, in particular, was to gauge the extent to which recent battlefield innovations used in the conflicts in Iraq/Afghanistan have shaped civilian practice.”
To determine which interventions to include, study authors used an expert physician/surgeon panel with both military and civilian representatives. Based on significant clinical data, the investigators opted to survey the use of DCR, tourniquets, hemostatic agents and prehospital interventions, including intraosseous catheter access and needle thoracostomy.
A 47-question survey was designed and administered to TMDs at 630 trauma centers across the country to assess the relevance and function of each of the four domains; 245 of the medical directors responded. Trauma centers reported high civilian use of DCR, but their adoption of the other interventions was spotty.
Sharing Best Practices
“It’s clear that civilian researchers have a significant role to play, in terms of conducting research that builds trauma surgeon awareness of military techniques and their translation to civilian settings,” noted lead author Adil Haider, MD, MPH, Kessler Director of the Center for Surgery and Public Health at Brigham and Women’s Hospital in Boston. “Governing bodies and supporting agencies like the IOM also have an important role to play, in terms of fostering partnerships between military and civilian trauma centers. The sharing of best practices and dissemination of findings will be essential as we look to broaden the evidence base for battlefield innovations, not just to improve care for frontline soldiers in future combat operations but to improve civilian trauma care, as well.”
A 2014 article published in JAMA Surgery noted that, with Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) the first prolonged conflicts the United States has been involved in since the Vietnam War, one of the most important advancements in combat trauma care was the adoption of DCR.2
The protocol, which involves the basic principles of early, balanced administration of blood products, aggressive correction of coagulopathy and the minimization of crystalloid fluids, has been credited with improvements in survival among severely injured patients, according to the Madigan Army Medical Center-led study.
To analyze injury patterns, early care and resuscitation among soldiers who died before and after implementation of DCR policies, the researchers reviewed data from the Joint Theater Trauma Registry (2002-2011) for combat hospitals. In-hospital deaths were divided into pre-DCR (before 2006) and DCR (2006-2011).
Results indicate that, of 57,179 soldiers admitted to a forward-combat hospital, 2,565 (4.5%) subsequently died at the hospital. The majority of patients, 74% were severely injured, with 80% of those dying within 24 hours of admission. Part of the reason was a shift in injury patterns with more severe head trauma cases in the later group.
DCR policies, however, were associated with a decrease in average 24-hour crystalloid infusion volume and increased use of fresh frozen plasma.
The average ratio of packed red blood cells to fresh frozen plasma changed from 2.6:1 during the pre-DCR period to 1.4:1 during the DCR period, according to study authors, who noted, “Patients who died in a hospital during the DCR period were more likely to be severely injured and have a severe brain injury, consistent with a decrease in deaths among potentially salvageable patients.”
1 Haider AH, Piper LC, Zogg CK, Schneider EB, Orman JA, Butler FK, Gerhardt RT, Haut ER, Mather JP, MacKenzie EJ, Schwartz DA, Geyer DW, DuBose JJ, Rasmussen TE, Blackbourne LH. Military-to-civilian translation of battlefield innovations in operative trauma care. Surgery. 2015 Dec;158(6):1686-95. doi:10.1016/j.surg.2015.06.026. Epub 2015 Jul 23. PubMed PMID: 26210224.
2 Langan NR, Eckert M, Martin MJ. Changing patterns of in-hospital deaths following implementation of damage control resuscitation practices in US forward military treatment facilities. JAMA Surg. 2014 Sep;149(9):904-12. doi: 10.1001/jamasurg.2014.940. PubMed PMID: 25029432.