Joint Trauma System, Defense Committee on Trauma, and Armed Services Blood Program consensus statement on whole blood

Stacy A. Shackelford; Jennifer M. Gurney; Audra L. Taylor; Sean Keenan; Jason B. Corley; Cord W. Cunningham; Brendon G. Drew; Shane D. Jensen; Russ S. Kotwal; Harold R. Montgomery; Erika T. Nance; Michael A. Remley; Andrew P. Cap;  ;

doi:10.1111/trf.16454

Saving Lives on the Battlefield: A Joint Trauma System Review of Pre-Hospital Trauma Care in Combined Joint Operating Area - Afghanistan (CJOA-A)

10.21236/ada573744 ◽

2013 ◽

Cited By ~ 5

Author(s):

Russ S. Kotwal ◽

Frank K. Butler ◽

Erin P. Edgar ◽

Stacy A. Shackelford ◽

Donald R. Bennett ◽

...

Keyword(s):

Trauma Care ◽

Trauma System ◽

System Review ◽

Joint Trauma

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Application of the Joint Trauma System Clinical Practice Guideline for Pain, Anxiety, and Delirium in a Combat Support Hospital in Iraq

Military Medicine ◽

10.1093/milmed/usz455 ◽

2019 ◽

Vol 185 (5-6) ◽

pp. e573-e578

Author(s):

Sandeep T Dhanjal ◽

Kalyn C Jannace ◽

Nicholas A Giordano ◽

Krista B Highland

Keyword(s):

Clinical Practice ◽

Physical Therapy ◽

Pain Intensity ◽

Acute Pain ◽

Clinical Practice Guideline ◽

Practice Guideline ◽

Clinical Characteristics ◽

Trauma System ◽

Pain Anxiety ◽

Joint Trauma

Abstract Introduction The 2017 Joint Trauma System Clinical Practice Guideline for Pain, Anxiety, and Delirium (JTS CPG) provides an evidence-based framework for managing pain, anxiety, and delirium in combat settings. In this study, we evaluate the use of multimodal analgesia and assess pain outcomes, as indicated by the JTS CPG, at the combat support hospital (CSH). Materials and Methods In this quality improvement project, data were collected for all patients, presenting to the CSH in Baghdad, Iraq, who received consultation from the acute pain service from October 10, 2017 to February 27, 2018. Univariate analyses described patient demographic and clinical characteristics. Defense and Veterans Pain Rating Scale (DVPRS) scores, physical therapy completion, and sleep duration were recorded for each patient daily. Correlations assessed relationships between variables, including clinical characteristics and DVPRS scores. Results 34 patients were included in this study. About 65% of the patients included in this study were Iraqi military, while the other 35% were U.S. or Coalition Forces. Over half received more than one class of analgesic medication. The majority of patients received regional anesthesia, with 17 different techniques utilized. The DVPRS had acceptable internal consistency (Cronbach alpha = 0.87, 95% CI 0.80, 0.95). There was a significant difference in median DVPRS pain intensity scores between those who met physical therapy goals and those who did not. Sleep duration was negatively correlated with both the DVPRS pain intensity and sleep scores. Conclusions This report indicates that acute pain service teams integrated in a CSH can feasibly implement JTS CPGs using a team-based approach. Given the military’s emphasis on managing complex pain and disability among survivors beginning in the combat environment, it is imperative that innovations and best practices, like the JTS CPG, be assessed in the combat setting.

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Practical Considerations for a Military Whole Blood Program

Military Medicine ◽

10.1093/milmed/usz466 ◽

2020 ◽

Vol 185 (7-8) ◽

pp. e1032-e1038 ◽

Cited By ~ 4

Author(s):

Marshall Bahr ◽

Andrew P Cap ◽

Devin Dishong ◽

Mark H Yazer

Keyword(s):

Whole Blood ◽

Prehospital Care ◽

Trauma System ◽

Current Evidence ◽

Cochrane Library ◽

Combat Casualty ◽

Resuscitation Guidelines ◽

The Cochrane Library ◽

The Military ◽

Combat Environment

Abstract Introduction Prehospital care in the combat environment has always been of great importance to the U.S. military, and trauma resuscitation has remained a cornerstone. More evidence continues to demonstrate the advantages of intervention with early transfusion of blood products at the point of injury. The military has recognized these benefits; as such, the Department of Defense Joint Trauma System and the Committee on Tactical Combat Casualty Care have developed new advanced resuscitation guidelines, which now encourage the use of whole blood (WB) in the prehospital setting. Materials and Methods This general review of peer-reviewed journal articles was performed through an extensive electronic search from the databases of PubMed Central (MEDLINE) and the Cochrane Library. Results Based on this literature search, the current evidence suggests that transfusion with WB is safe and efficacious. Additionally, soldier function is preserved after donating fresh WB in the field. Currently, the collection and implementation of WB is accomplished through several different protocol-driven techniques. Conclusion WB has become the favored transfusion product as it provides all of the components of blood in a convenient package that is easy to store and transport. Specifically, group O WB containing low titers of anti-A and -B antibodies has become the transfusion product of choice, offering the ability to universally fluid resuscitate patients despite not knowing their blood group. This new ability to obtain low titer group O WB has transformed the approach to the management of hemorrhagic shock in the prehospital combat environment.

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788. Enterobacter cloacae Infection Characteristics and Outcomes in Military Personnel who Sustained Trauma in Iraq and Afghanistan

Open Forum Infectious Diseases ◽

10.1093/ofid/ofab466.985 ◽

2021 ◽

Vol 8 (Supplement_1) ◽

pp. S490-S491

Author(s):

William N Bennett ◽

Joseph Yabes ◽

Katrin Mende ◽

Miriam Beckius ◽

Azizur Rahman ◽

...

Keyword(s):

Injury Severity ◽

Trauma System ◽

Enterobacter Cloacae ◽

Antibiotic Use ◽

Multidrug Resistant ◽

Clinical Infection ◽

Median Hospital Stay ◽

Surgical Interventions ◽

Joint Trauma ◽

To Receive

Abstract Background Enterobacter cloacae is a Gram-negative rod with chromosomally-induced Amp-C β-lactamase with multidrug-resistant potential. Joint Trauma System guidelines for treating combat wounds include prophylaxis with cefazolin and ertapenem, potent inducers of Amp-C. We evaluated clinical characteristics, antibiotic utilization, and outcomes associated with battlefield-related E. cloacae infections. Methods All initial solitary (those with single isolates) and serial E. cloacae isolates (≥24 hours from initial isolate from any site) were collected from the Trauma Infectious Disease Outcomes Study (6/2009-12/2014). Inclusion required E. cloacae isolation from a clinical infection. Amp-C-inducing β-lactams were classified based on induction potential and lability to the Amp-C β-lactamase as Amp-C induction levels. Results Of 653 E. cloacae isolates, 253 met inclusion criteria – 64 patients had only initial isolates, 54 patients had serial isolates. Patients were largely male (99%), median age 23 years (IQR 21-27), with injury severity score of 34 (IQR 24-45). Initial isolates were wound (70%), respiratory (22%), blood (7%), urine (1%), and other (1%). Patients commonly had blast injuries (89%), required ICU admission (95%), and had a median hospital stay of 57 days (IQR 39-82). Patients with serial isolates showed a trend towards earlier clinical infection (5 vs 8 days, P = 0.07). They were also less likely to receive carbapenems prior to E. cloacae isolation compared to those with only initial isolates (4% vs 38%) and more likely to receive 1st generation cephalosporins (79% vs 58%, P = 0.01). The serial isolate group received more days of 1st generation cephalosporins (median 6 days vs 2.5 days, P = 0.01). Cumulative antimicrobial therapy trended towards significance and was greater with the serial isolates (median 100 days vs 74 days, P = 0.08). There was no difference in number of surgical interventions between those with and without serial isolates (P = 0.54). Overall, 6 patients died. Conclusion E. cloacae infections after battlefield trauma were frequently encountered and associated with exposure to 1st generation cephalosporins. Serial infections did not correlate to worse patient outcomes but displayed a trend towards an overall greater duration of antibiotic use. Disclosures William N. Bennett, V, MD, Abbvie (Shareholder)Amgen (Shareholder)Nabriva (Shareholder)

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The Joint Trauma System: History in the Making

Military Medicine ◽

10.1093/milmed/usy166 ◽

2018 ◽

Vol 183 (suppl_2) ◽

pp. 4-7

Author(s):

Mary Ann Spott ◽

Cynthia R Kurkowski ◽

Zsolt Stockinger

Keyword(s):

Trauma System ◽

Joint Trauma

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Joint Trauma System (JTS)

Encyclopedia of Trauma Care ◽

10.1007/978-3-642-29613-0_392 ◽

2015 ◽

pp. 861-862

Author(s):

Mary Ann Spott ◽

Donald H. Jenkins

Keyword(s):

Trauma System ◽

Joint Trauma

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After the Battlefield: Infectious Complications among Wounded Warriors in the Trauma Infectious Disease Outcomes Study

Military Medicine ◽

10.1093/milmed/usz027 ◽

2019 ◽

Vol 184 (Supplement_2) ◽

pp. 18-25 ◽

Cited By ~ 2

Author(s):

David R Tribble ◽

Clinton K Murray ◽

Bradley A Lloyd ◽

Anuradha Ganesan ◽

Katrin Mende ◽

...

Keyword(s):

Infectious Disease ◽

Clinical Practice ◽

Trauma System ◽

Multidrug Resistant ◽

Infectious Complications ◽

Trauma Patients ◽

Related Data ◽

Initial Hospitalization ◽

Joint Trauma

Abstract Introduction During recent wars in Iraq and Afghanistan, improved survivability in severe trauma corresponded with a rise in the proportion of trauma-related infections, including those associated with multidrug-resistant organisms (MDROs). Significant morbidity was reported in association with the infections. There is also concern regarding potential long-term impacts of the trauma-related infectious complications. Therefore, to meet the critical need of prospective collection of standardized infection-related data to understand the disease burden and improve outcomes of wounded personnel, the Trauma Infectious Disease Outcomes Study (TIDOS) was developed. Herein, we review accomplishments and key peer-reviewed findings of TIDOS. Methods The TIDOS project is a multicenter observational study of short- and long-term infectious complications following deployment-related trauma. Wounded military personnel medevac’d to Landstuhl Regional Medical Center (LRMC; Germany) before transfer to a participating US military hospital between June 2009 and December 2014 were eligible for inclusion. An infectious disease module to supplement the Department of Defense Trauma Registry by collecting infection-related data from all trauma patients admitted to participating hospitals was developed. Specimens from trauma patients were also collected and retained in a microbiological isolate repository. During the initial hospitalization, patients were given the opportunity to enroll in a prospective follow-up cohort study. Patients who received Department of Veterans Affairs (VA) care were also given the opportunity to consent to ongoing VA follow-up Results A total of 2,699 patients transferred to participating military hospitals in the USA, of which 1,359 (50%) patients enrolled in the TIDOS follow-up cohort. In addition, 638 enrolled in the TIDOS-VA cohort (52% of TIDOS enrollees who entered VA healthcare). More than 8,000 isolates were collected from infection control surveillance and diagnostic evaluations and retained in the TIDOS Microbiological Repository. Approximately 34% of the 2,699 patients at US hospitals developed a trauma-related infection during their initial hospitalization with skin and soft-tissue infections being predominant. After discharge from the US hospitals, approximately one-third of TIDOS cohort enrollees developed a new trauma-related infection during follow-up and extremity wound infections (skin and soft-tissue infections and osteomyelitis) continued to be the majority. Among TIDOS cohort enrollees who received VA healthcare, 38% developed a new trauma-related infection with the incident infection being diagnosed a median of 88 days (interquartile range: 19–351 days) following hospital discharge. Data from TIDOS have been used to support the development of Joint Trauma System clinical practice guidelines for the prevention of combat-related infections, as well as the management of invasive fungal wound infections. Lastly, due to the increasing proportion of infections associated with MDROs, TIDOS investigators have collaborated with investigators across military laboratories as part of the Multidrug-Resistant and Virulent Organisms Trauma Infections Initiative with the objective of improving the understanding of the complex wound microbiology in order to develop novel infectious disease countermeasures. Conclusions The TIDOS project has focused research on four initiatives: (1) blast-related wound infection epidemiology and clinical management; (2) DoD-VA outcomes research; (3) Multidrug- Resistant and other Virulent Organisms Trauma Infections Initiative; and (4) Joint Trauma System clinical practice guidelines and antibiotic stewardship. There is a continuing need for longitudinal data platforms to support battlefield wound research and clinical practice guideline recommendation refinement, particularly to improve care for future conflicts. As such, maintaining a research platform, such as TIDOS, would negate the lengthy time needed to initiate data collection and analysis.

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Trauma System Development and the Joint Trauma System

Front Line Surgery ◽

10.1007/978-3-319-56780-8_44 ◽

2017 ◽

pp. 761-774

Author(s):

Kirby R. Gross ◽

Brian Eastridge ◽

Jeffrey A. Bailey ◽

M. Margaret Knudson

Keyword(s):

System Development ◽

Trauma System ◽

Joint Trauma

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Operationalizing the Deployment of Low-Titer O-Positive Whole Blood Within a Regional Trauma System

Military Medicine ◽

10.1093/milmed/usaa283 ◽

2021 ◽

Vol 186 (Supplement_1) ◽

pp. 391-399

Author(s):

Randall Schaefer ◽

Tasia Long ◽

David Wampler ◽

Rena Summers ◽

Eric Epley ◽

...

Keyword(s):

Whole Blood ◽

Trauma Center ◽

Research Effort ◽

Damage Control ◽

Trauma System ◽

Active Management ◽

Cold Chain ◽

Advisory Council ◽

Blood Product Transfusion ◽

Emergency Medical

ABSTRACT Introduction The implementation of a low-titer O+ whole blood (LTOWB) resuscitation algorithm, particularly in the prehospital environment, has several inherent challenges, including cost, limited and inconsistent supply, and the logistics of cold-chain management. The Southwest Texas Regional Advisory Council has implemented the nation’s first multidisciplinary, multi-institutional regional LTOWB program. This research effort was to illustrate the successful deployment of LTOWB within a regional trauma system. Materials and Methods A deliberate systems approach to the deployment of LTOWB was used. Tenets of this program included the active management of blood donor sources and blood supply levels to minimize wastage as a result of expiration, maximize product utilization, the use of prehospital transfusion triggers, and efforts to decrease program costs prehospital agencies. A novel LTOWB rotation system was established using the concept of a “rotation site” and “rotation center.” Standardized transfusion criteria, a regional approved equipment list, a regional Prehospital Blood Product Transfusion Record, and a robust multilevel communication plan serves as the framework for the program. The San Antonio Whole Blood Consortium was developed to create a consensus driven forum to manage and guide the program. Results From January 2018 to October 2019, LTOWB has been placed at 18 helicopter emergency medical services (HEMS) bases, 12 ground emergency medical service (EMS) agencies, 1 level I trauma center, and 1 level IV trauma center. A total of 450 patients have received a prehospital LTOWB transfusion. Program wide, the wastage rate of LTOWB due to expiration is between 1% and 2%. No complications related to prehospital LTOWB administration have been identified. Discussion This work demonstrates a novel model for the development of a trauma system LTOWB program. The program’s implementation augments remote damage control resuscitation strategies and requires the integration and collaboration of a multidisciplinary stakeholder team to optimize efficiency, performance, and safety of the program.

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