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Introduction Far-Forward Damage Control Laparotomies (DCLs) might provide direct-compression of visceral hemorrhage, however, suturing is a limiting factor, especially for non-physicians. We thus compared abbreviated skin closures comparing skin-suture (SS) versus wound-clamp (WC), on-board a research aircraft in weightlessness (0g) and normal gravity (1g). Methods Surgeons conducted DCLs on a surgical-simulator; onboard the hangered-aircraft (1g), or during parabolic flight (0g), randomized to either WC or SS. Results Ten surgeons participated. Two (40%) surgeons randomized to suture in 0g were incapacitated with motion-sickness, and none were able to close in either 1 or 0g. With WC, two completely closed in 1g as did three in 0g, despite having longer incisions (p = 0.016). Overall skin-closure with WC was significantly greater in both 1g (p = 0.016) and 0g (p = 0.008). Conclusions WC was more effective in 1g and particularly 0g. Future studies should address the utility of abbreviated WC abdominal closure to facilitate potential Far-Forward DCL. Trial registration ID ISRCTN/77929274.

BACKGROUND: Care in a trauma centre is associated with significant reductions in mortality after severe injury. However, emerging evidence suggests that outcomes across similarly accredited trauma centres are not equivalent, even after adjusting for case-mix. The primary objective of this analysis was to evaluate secular trends in overall mortality at trauma centres. Secondarily, we explored trauma centre-specific mortality to determine the extent of variation between centres. METHODS: Data on 26 421 adults (≥□18 yr) admitted to a trauma centre between 2005 and 2011 were derived from the Ontario Trauma Registry. We used generalized estimating equations to calculate in-hospital mortality over time and hierarchical models to estimate trauma-centre-specific mortality. To quantify variability between centres, we calculated median odds ratios. Adjusted odds of death were calculated for each trauma centre to identify those with higher than expected, average and lower than expected mortality. RESULTS: Overall mortality at trauma centres decreased from 13.2% in 2005 to 11.2% in 2009. After adjusting for case mix, the odds of death decreased by approximately 3% a year (95% confidence interval 0%-5%). Trauma centre-specific mortality ranged from 11.4% to 13.1%. After adjusting for case mix, differences in trauma centre-specific mortality were observed (median odds ratio = 1.25), suggesting that the odds of dying could be 1.25-fold greater if the same patient was admitted to 1 randomly selected trauma centre as opposed to another. Differences were most pronounced for patients with isolated head injuries and among older patients as evidenced by higher median odds ratios and the number of outliers. INTERPRETATION: We observed a significant improvement over time in the mortality of severely injured patients cared for at Ontario's trauma centres. However, considerable differences in trauma centre-specific mortality were observed. Differences were most pronounced among older injured patients and those with isolated traumatic brain injury. System-wide performance improvement initiatives should target these subgroups. Language: en

Introduction Over the past decade, the health care industry has witnessed an unparalleled reporting of hospital-specific comparative outcomes. Clearly, there has been a growing consensus among a broad array of agencies and institutions around the importance of reporting quality measures, including those that measure clinical outcomes. Previous research suggests that there is substantial variability in care between hospitals, particularly in trauma centres. In 2006, the American College of Surgeons (ACS) Committee on Trauma launched the Trauma Quality Improvement Program (TQIP) to study the variability in outcomes between trauma centers to improve the quality of trauma care in North America. The primary goal of TQIP is to improve the quality of trauma care through outcomes-based, risk-adjusted benchmarking of trauma centers and feedback reports. However, differences in patient selection (selection bias), case mix, data quality, geography, and other factors inherent to different injured populations likely contribute in part to observed differences in outcome. Risk-adjustment is a methodology used to ensure that “like” patients are being compared, so that differences in outcome can be attributed solely to differences in the processes and quality of care provided. Transport services are beginning to use performance metrics to analyze for variations between ambulance and transport services in order to improve quality of care during transport. The “Ground Air Medical qUality Transport Quality Improvement” (GAMUT) Collaborative collects transport data in a large database to use as a free resource for transport teams to track, report, and analyze their performance on transport-specific quality metrics by comparing it to other program's. Because of the nature of transport, most of the metrics are process metrics or intermediate outcomes. Arguably, the only transport-related definitive outcome that GAMUT reports is rate of cardiac arrest during transport (Rate of CPR performed during transport). However, this rate is reported as an unadjusted rate: there is no risk-adjustment. We propose a simple methodology to allow for risk-adjustment of CPR rate during transport. Methods Ornge is the sole provider of Air Ambulance and Critical Care Transport Services to the province of Ontario, Canada. The province has a land mass of over 1 million square kilometers, and has a population of almost 14 million people. Ornge operates a fleet of Pilatus Next Generation PC-12 airplanes, Leonardo AW-139 helicopters, and Crestline Commander land ambulances, staffed with Critical Care and Advanced Care Paramedics. For low acuity patients requiring a lower level of care, Ornge uses a Standing Agreement to Chart Air Ambulance services from contract carriers, staffed by primary care paramedics. For interfacility transfer patients, we propose to compare CPR rates year over year for Ornge (2013-2017). SA transports will not be included, as they represent a very low-risk group. Risk adjustment will be done by adjusting for mechanical ventilation (yes/no), use of infusion(s) of vasopressors (yes/no), mechanical ventilation and pressors (yes/no), or none. Rates will be standardized to the distribution of cases during the reference year of 2013-14, and reported per thousand hours. Results Discussion Comparing variability in outcomes is helpful in improving quality of care. High performing centres can share their best practices to improve quality of care throughout the system. Risk adjustment is a methodology used to ensure that “apples” are being compared to “apples”, and that case selection is not affecting the analysis. Transport agencies are now reporting CPR rates during transports as an outcome measure, as part of their quality improvement programs. These rates are unadjusted, and are difficult to compare across groups. Air ambulances transport many different types of patients, such that standard risk adjustment methods may not be directly applicable. Risk adjustment for trauma patients is completely different than for post STEMI patients. As well, transport agencies only care for patients during a very short period of time. We presented a methodology of risk-adjustment for CPR rates during interfacility transports that have correlational validity with our changes in our quality processes over time.

Introduction Approximately fifty percent of Canada's Indigenous population resides in remote and rural communities, where life expectancy is five to seven years shorter than in the rest of Canada. Barriers to health care include, but are not limited to: low population density, long transportation and wait times, high rates of staff turnover, harsh weather climates, and inadequate human resources. Ornge is the air ambulance and critical care transport provider for the province of Ontario. Ontario is Canada's second largest province, with a landmass of more than 1 million km2, and a population of about 13 million people. Northern Ontario constitutes 87% of the land area of the province, but has less than 7% of the population. Ornge operates 12 bases across the province, and employs a fleet of 8 Pilatus PC-12 fixed wing aircraft and 11 AW 139 rotor wing aircraft to support the air ambulance transport needs of the province. As well, Ornge utilizes contract air carriers to provide transport for predominantly low acuity patients. We hypothesized that air ambulance services have the medical, logistical, educational, and technological and data capabilities to improve access to care for remote Indigenous communities. Increasing involvement of air ambulance services in delivering health care to remote Indigenous communities will improve patient outcomes and represent an opportunity for air ambulance services to expand their scope of work. Methods Ornge has developed a five-part strategy to help improve access to care for Indigenous communities. Results 1. Telemedicine: Over the past year, Ornge has conducted approximately 75 telemedicine consultations with the nurses servicing four remote indigenous communities. Survey data from the nurses has uniformly been extremely positive of the value of the telemedicine support. 2. Point of Care Lab Tests: Over the past six months, 58 patients within two communities have benefitted from point of care lab tests supplied by Ornge. Patient care has been improved dramatically and unnecessary transports have been prevented. 3. Education: Ornge has delivered educational sessions to nurses and doctors servicing these remote communities. This has improved the working relationships between all parties. As well, Ornge has helped develop a proposal to train indigenous members as first responders within seven remote communities. 4. Outreach: Ornge has delivered three sessions of first aid/cpr and "Stop the Bleed" training to Indigenous youth. As well, Ornge is now delivering Primary and Secondary Injury and Opioid prevention sessions to Indigenous Youth. 5. Data: Stakeholders are now using Ornge data to help identify strategies to improve access to care for Indigenous communities. Conclusion Air ambulance services have the expertise and capabilities to help improve access to care for remote Indigenous communities. This represents an area of potential opportunity for air ambulance services. Expanding the mandate of air ambulance services to improving access to care to these remote communities can help improve patient outcomes, allow for care closer to home, and allows for accurate triaging of air ambulance assets in a relative resource-poor environment.

Traumatic injury is increasing in importance in all settings and environments worldwide. Many preventable deaths are from conditions that are common and treatable. However, as potentially lethal injuries often induce progressive and frequently irreversible physiologic decline, the timing of interventions is critical. Invasive treatments may need to be offered by prehospital care providers who lack extensive training and practice. Telementoring allows experienced experts to guide less experienced providers remotely using information technology (IT). Early experience has shown that these techniques are practical and considered valuable. Their translation to regular practice, however, will require the immediate availability of appropriately trained remote experts willing to serve as mentors. Acute care trauma specialists are acclimatized to responding to out-of-hospital consultations and assuming overall responsibility for critical physiology and transport and may serve as the backbone of such a national/ international call response initiative.

Bleeding to death is the most preventable cause of posttraumatic death worldwide. Despite the fact that many of these deaths are anatomically salvageable with relatively basic surgical interventions, they remain lethal in actuality in prehospital environments when no facilities and skills exist to contemplate undertaking basic damage control surgery (DCS). With better attention to prehospital control of extremity hemorrhage, intracavitary bleeding (especially intraperitoneal) remains beyond the scope of prehospital providers. However, recent revolutions in the informatics and techniques of telementoring (TMT), DCS and highly realistic accelerated training of motivated first responders suggests that basic life-saving DCS may have applicability to save bleeding patients in austere environments previously considered unsalvageable. Especially with informatic advances, any provider with Internet connectivity can potentially be supported by highly proficient specialists with content expertise in the index problem. This unprecedented TMT support may allow highly motivated but inexperienced personnel to provide advanced surgical interventions in extreme environments in many austere locations both on and above the planet.

Background: Hemorrhage coupled with coagulopathy remains the leading cause of preventable in-hospital deaths among trauma patients. Use of a transfusion protocol with a predefined ratio of 1:1:1 (1 each of red blood cells [RBC], frozen plasma [FP] and platelets) has been associated with improved survival in retrospective studies in military and civilian settings, but such a protocol has its challenges and may increase the risk of respiratory complications. We conducted a randomized controlled trial to assess the feasibility of a 1:1:1 transfusion protocol and its effect on mortality and complications among patients with severe trauma. Methods: We included 78 patients seen in a tertiary trauma centre between July 2009 and October 2011 who had hypotension and bleeding and were expected to need massive transfusion (≥ 10 RBC units in 24 h). We randomly assigned them to either the fixed-ratio (1:1:1) transfusion protocol ( n = 40) or to a laboratory-results–guided transfusion protocol (control; n = 38). The primary outcome, feasibility, was assessed in terms of blood product ratios and plasma wastage. Safety was measured based on 28-day mortality and survival free of acute respiratory distress syndrome. Results: Overall, a transfusion ratio of 1:1:1 was achieved in 57% (21/37) of patients in the fixed-ratio group, as compared with 6% (2/32) in the control group. A ratio of 1:1 (RBC:FP) was achieved in 73% (27/37) in the fixed-ratio group and 22% (7/32) in the control group. Plasma wastage was higher with the intervention protocol (22% [86/390] of FP units v. 10% [30/289] in the control group). The 28-day mortality and number of days free of acute respiratory distress syndrome were statistically similar between the groups. Interpretation: The fixed-ratio transfusion protocol was feasible in our study, but it was associated with increased plasma wastage. Larger randomized trials are needed to evaluate the efficacy of such a protocol in trauma care. Trial registration: ClinicalTrials.gov, no. NCT00945542

Background Patients with an occult pneumothoraces (OPTXs) may be at risk of tension pneumothoraces (TPTXs) without drainage or pleural drainage complications if treated. Methods Adults with traumatic OPTXs and requiring positive-pressure ventilation (PPV) were randomized to pleural drainage or observation (one side only enrolled if bilateral). All subsequent care and method of pleural drainage was per attending physician discretion. The primary outcome was a composite of respiratory distress (RD) (need for urgent pleural drainage, acute/sustained increases in O2 requirements, ventilator dysynchrony, and/or charted respiratory events). Results Ninety severely injured patients (mean [SD], Injury Severity Score [ISS], 33 [11]) were studied at four centers: Calgary (55), Toronto (27), Quebec (6), and Sherbrooke (3). Forty were randomized to tube thoracostomy, and 50 were randomized to observation. The risk of RD was similar between the observation and tube thoracostomy groups (relative risk, 0.71; 95% confidence interval, 0.40-1.27). There was no difference in mortality or intensive care unit (ICU), ventilator, or hospital days between groups. In those observed, 20% required subsequent pleural drainage (40% PTX progression, 60% pleural fluid, and 20% other). One observed patient (2%) undergoing PPV at enrollment had a TPTX, which was treated with urgent tube thoracostomy without sequelae. Drainage complications occurred in 15% of those randomized to drainage, while suboptimal tube thoracostomy position occurred in an additional 15%. There were three times (24% vs. 8%) more failures and more RDs (p = 0.01) among those observed with OPTXs requiring sustained PPV versus just for an operation, which increases threefold after a week in the ICU (p = 0.07). Conclusion Our results suggest that OPTXs may be safely observed in hemodynamically stable patients undergoing PPV just for an operation, although one third of those requiring a week or more of ICU care received drainage, and TPTXs still occur. Complications of pleural drainage remain unacceptably high, and future work should attempt to delineate specific factors among those observed that warrant prophylactic drainage. Level of evidence Therapeutic study, level III.

Helicopter emergency medical services (HEMS) have become an engrained component of trauma systems. In Ontario, transportation for trauma patients is through one of three ways: scene call, modified scene call, or interfacility transfer. We hypothesize that differences exist between these types of transports in both patient demographics and patient outcomes. This study compares the characteristics of patients transported by each of these methods to two level 1 trauma centers and assesses for any impact on morbidity or mortality. As a secondary outcome reasons for delay were identified.A local trauma registry was used to identify and abstract data for all patients transported to two trauma centers by HEMS over a 36-month period. Further chart abstraction using the HEMS patient care reports was done to identify causes of delay during HEMS transport.During the study period HEMS transferred a total of 911 patients of which 139 were scene calls, 333 were modified scene calls and 439 were interfacility transfers. Scene calls had more patients with an ISS of less than 15 and had more patients discharged home from the ED. Modified scene calls had more patients with an ISS greater than 25. The most common delays that were considered modifiable included the sending physician doing a procedure, waiting to meet a land EMS crew, delays for diagnostic imaging and confirming disposition or destination.Differences exist between the types of transports done by HEMS for trauma patients. Many identified reasons for delay to HEMS transport are modifiable and have practical solutions. Future research should focus on solutions to identified delays to HEMS transport. Key words: helicopter emergency medical services; trauma; prehospital care; delays.

Background Torso bleeding remains the most preventable cause of post-traumatic death worldwide. Remote damage control resuscitation (RDCR) endeavours to rescue the most catastrophically injured, but has not focused on prehospital surgical torso hemorrhage control (HC). We examined the logistics and metrics of intraperitoneal packing in weightlessness in Parabolic flight (0g) compared to terrestrial gravity (1g) as an extreme example of surgical RDCR. Methods A surgical simulator was customized with high-fidelity intraperitoneal anatomy, a "blood" pump and flowmeter. A standardized HC task was to explore the simulator, identify "bleeding" from a previously unknown liver injury perfused at 80 mm Hg, and pack to gain hemostasis. Ten surgeons performed RDCR laparotomies onboard a research aircraft, first in 1g followed by 0g. The standardized laparotomy was sectioned into 20-second segments to conduct and facilitate parabolic flight comparisons, with "blood" pumped only during these time segments. A maximum of 12 segments permitted for each laparotomy. Results All 10 surgeons successfully performed HC in both 1g and 0g. There was no difference in blood loss between 1g and 0g (p = 0.161) or during observation following HC (p = 0.944). Compared to 1g, identification of bleeding in 0g incurred less "blood" loss (p = 0.032). Overall surgeons rated their personal performance and relative difficulty of surgery in 0g as "harder" (median Likert, 2/5). However, conducting all phases of HC were rated equivalent between 1g and 0g (median Likert, 3/5), except for instrument control (rated slightly harder, 2.75/5). Conclusion Performing laparotomies with packing of a simulated torso hemorrhage in a high-fidelity surgical simulator was feasible onboard a research aircraft in both normal and weightless conditions. Despite being subjectively "harder," most phases of operative intervention were rated equivalently, with no statistical difference in "blood" loss in weightlessness. Direct operative control of torso hemorrhage is theoretically possible in extreme environments if logistics are provided.

Unlike penetrating abdominal injuries where the decision to operate is relatively straight forward, those combat casualties that sustain blunt abdominal trauma offer more of a diagnostic and clinical challenge. For unstable patients with a positive focused abdominal sonography in trauma or diagnostic peritoneal lavage, exploratory laparotomy should be undertaken immediately. All grade IV-V splenic injuries should undergo splenectomy, patients undergoing attempted splenic salvage should be monitored in the Role 3 facility and embolization of such splenic injuries may be considered if available. Patients who fail non-operative management of the spleen require splenectomy at the Role 3 prior to aeromedical evacuation. Overwhelming post-splenectomy infection is a serious disease that can progress from a mild flu-like illness to fulminant sepsis in a short period of time. Although relatively rare, it has a high mortality rate with delayed or inadequate treatment. All splenectomized patients and those deemed to be functionally asplenic should be vaccinated within 14 days from splenectomy and prior to aeromedical evacuation.

BACKGROUND: Over half of severely injured patients are initially transported from the scene of injury to non-trauma centers (NTC), with many requiring subsequent transfer to trauma center (TC) care. Definitive care in the setting of severe injury is time sensitive. However, transferring severely injured patients from a NTC is complex process often fraught with delays. Selection of the receiving TC and the mode of interfacility transport both strongly influence total transfer time, and are highly amenable to quality improvement initiatives. METHODS: We analyzed transfer strategies, defined as the pairing of a destination and mode of transport (land vs. rotary-wing vs. fixed-wing), for severely injured adult patients. Existing transfer strategies at each NTC were derived from trauma registry data. Geographic Information Systems network analysis was used to identify the strategy that minimized transfer times the most as well as alternate strategies (+15 or +30 minutes) for each NTC. Transfer network efficiency was characterized based on optimality and stability. RESULTS: We identified 7,702 severely injured adult patients transferred from 146 NTCs to 9 TCs. NTCs transferred severely injured patients to a median of 3 (IQR1-4) different TCs and utilized a median of 4 (IQR 2-6) different transfer strategies. After allowing for the use of alternate transfer strategies, 73.1% of severely injured patients were transported using optimal/alternate strategies and only 40.4% of NTCs transferred >90% of patients using an optimal/alternate transfer strategy. Three quarters (75.5%) of transfers occurred between NTCs and their most common receiving TC. CONCLUSIONS: More than a quarter of patients with severe traumatic injuries undergoing inter-facility transport to a TC in Ontario are consistently transported using a non-optimal combination of destination and mode of transport. Our novel analytic approach can be easily adapted to different system configurations and provides actionable data that can be provided to NTCs and other stakeholders. LEVEL OF EVIDENCE: IV STUDY TYPE: mixed-methods retrospective cohort study and Geographic information Systems network analysis. Language: en

Tactical Combat Casualty Care (TCCC) is intended to treat potentially preventable causes of death on the battlefield, but acknowledges that application of these treatments may place the provider and even the mission in jeopardy if performed at the wrong time. Therefore, TCCC classifies the tactical situation with respect to health care provision into 3 phases (care under fire, tactical field care and tactical evacuation) and only permits certain interventions to be performed in specific phases based on the danger to the provider and casualty. In the 6 years that the Canadian Forces (CF) have been involved in sustained combat operations in Kandahar, Afghanistan, more than 1000 CF members have been injured and more than 150 have been killed. As a result, the CF gained substantial experience delivering TCCC to wounded soldiers on the battlefield. The purpose of this paper is to review the principles of TCCC and some of the lessons learned about battlefield trauma care during this conflict.

BACKGROUND: The use of international normalized ratio (INR) to diagnose vitamin K-dependent coagulation factor (VitK-CF) deficiency in trauma has limitations (inability to predict bleeding and long turnaround times). Thromboelastography (TEG) assesses the entire coagulation process. With TEG, reaction time (TEG-R) is used to assess global coagulation factor activity and takes less than 10 minutes. We assessed the ability of TEG-R to detect VitK-CF deficiency in trauma, compared to the INR. STUDY DESIGN AND METHODS: A total of 219 trauma patients with INR, TEG, and all VitK-CF measured at admission were included. Demographics and laboratory tests, drugs, blood transfusions, and severity scores were analyzed. Specificity, sensitivity, positive predictive value (PPV), and negative predictive value (NPV) of INR (≥1.3 and ≥1.5) and TEG-R (>8 min) to diagnose VitK-CF deficits (≤50%) were calculated. Secondary outcomes included time to INR and TEG results. RESULTS: Overall, TEG-R performed worse than INR. TEG-R had a sensitivity of 33% (95% CI, 16%-55%), specificity of 95% (95% CI, 91%-98%), PPV of 47% (95% CI, 23%-72%), and NPV of 92% (95% CI, 87%-95%). An INR of 1.5 or greater had a sensitivity of 67% (95% CI, 45%-84%), specificity of 98% (95% CI, 96%-99.7%), PPV of 84% (95% CI, 60%-97%), and NPV of 96% (95% CI, 92%-98%). An INR of 1.3 or greater also had better sensitivity, PPV, and NPV. For patients on warfarin, the times to INR results and TEG completion were 58 (±23) and 92 (±40) minutes (p = 0.07), respectively. TEG-R was abnormal in only one patient on warfarin. CONCLUSION: Our study suggests that TEG-R is not superior at identifying VitK-CF deficiency compared to INR in trauma.

Mass casualty incidents (MCIs) occur as a result of natural disasters, transportation incidents, terrorism or other means and result in more patients than locally available resources can generally manage.1 Owing to a variety of human and natural factors, such events have been occurring with increasing frequency and with increasingly devastating consequences.2,3 Detailed analyses of prior MCIs have provided insight into the management of these incidents. The US Department of Homeland Security has developed 15 plausible natural and manmade disaster scenarios that would result in large numbers of casualties. Most of these scenarios predict hundreds to thousands of critically injured patients, who would overwhelm existing disaster responses.4,5 Canada’s role in international affairs might not make it a prime target for terrorism; however, a review of the Canadian Disaster Database suggests that an all-hazards plan capable of dealing with natural, technological and terrorism-related MCIs is required (Table 1).6 Table 1 Deaths and injuries from disasters since 1980 in Canada* As a result of their constant readiness to treat injured patients, trauma centres and the trauma systems of which they are a part are an essential resource for regional responses to MCIs.7 This readiness is based on the availability of skilled personnel, life-support equipment, blood and blood products and diagnostic tools.8 On a smaller scale, trauma centre preparedness is tested with large-scale industrial accidents, high-speed motor vehicle collisions and shootings all involving multiple patients, such that multiple-casualty events and emergency department surges are challenges met daily in all of the country’s trauma centres. It is commonly believed that trauma centre disaster pre-paredness is a priority and that it has been optimized to the greatest extent possible. However, reviews of a number of recent MCIs, such as the 9/11 New York terrorist attacks, the London and Madrid bombings and Hurricane Katrina, suggest that trauma centres’ preparedness is limited in several critical domains. These domains include leadership,9 hazard planning,9 communications,9–14 sustainability of peak operations,15 education,16 interagency cooperation17 and funding.18 These vulnerabilities have been identified previously by the World Health Organization (WHO)1 and by centres that have provided assistance during MCIs.9–15,17 These deficiencies also indicate that the medical and surgical response to disasters is heavily dependent on an array of nonmedical institutions and external services and needs to be integrated into a regional response. With this background, we set out to evaluate Canadian trauma centres’ MCI preparedness and the extent of their integration into a regional response to MCIs.

Introduction Ornge is the sole air ambulance service in Ontario, Canada and provide interfacility transfers for severely ill patients. Sometimes the closest aircraft or most optimal resource is unavailable resulting in a transport delay. These patients may experience a clinical deterioration as a result. The primary objective of this study is to determine if a non-optimal transfer strategy is associated with a clinical deterioration as measured by a change in Rapid Emergency Medicine Score (REMS) compared to patients with an optimal transfer strategy. The secondary objective was to determine which factors were associated with a non-optimal transfer strategy. Methods This was a retrospective population-based cohort study using a health administrative database looking at all emergent adult interfacility transfers over a 5-year period. All interfacility transfers during that time were analyzed by sending-receiving pair and mean overall transport times calculated for reach unique resource to determine the fastest and most utilized resource for each sending-receiving pair. An optimal transfer strategy was defined by three conditions 1) the resource used was both the fastest and most utilized 2) the fastest fixed-wing resource if distance was greater than 240 km or 3) the fastest rotor-wing resource if distance was less than 240 km. The primary outcome, delta REMS was calculated by subtracting the REMS at time of request from the REMS at time of paramedic arrival. Therefore an increase in delta REMS would correlate with a clinical deterioration of a patient. Descriptive statistics were performed on patient, paramedic, institutional and time-level factors. A generalized linear model was used to determine the effect of transfer strategy on change in REMS score while adjusting for the other variables of interest and accounting for clustering by sending facility. For the secondary outcome a logistic regression model was used to explore factors associated with a non-optimal transfer strategy. Results The final study cohort included 9,687 patients and the median delay in interfacility transfer caused by a non-optimal transfer strategy was 35.7 minutes. Transfer strategy did not significantly affect change in REMS (beta coefficient 0.002; 95% CI: -0.08 - 0.82) in the adjusted linear regression model. The only patient characteristic found to be associated with a change in REMS in both the unadjusted and adjusted analysis was whether the patient was mechanically ventilated. Paramedic level of care of advanced (OR 0.37; 95% CI: 0.22 - 0.63) and critical care (OR 0.28; 95% CI: 0.16 - 0.49) as well as spring season (OR 0.75; 95% CI: 0.66 - 0.84) had lower odds of non-optimal transfer strategy in the generalized logistic regression model. Additionally, nursing stations had higher odds of non-optimal transfer strategy (OR 2.84; 95% CI: 1.19 - 6.83). Conclusion In conclusion, in this study population a non-optimal transfer strategy for air ambulance interfacility transfers did not result in patient deterioration as measured by a change in REMS score. Additionally, decreasing sending facility size was associated with higher odds of non-optimal transfer strategy while patients on a ventilator, requiring advance or critical care level of care and spring season had lower odds of non-optimal transfer strategy.

Thoracic injuries are potentially responsible for 25% of all trauma deaths. Chest X-ray is commonly used to screen patients with chest injury. However, the use of computed tomography (CT) scan for primary screening is increasing, particularly for blunt trauma. CT scans are more sensitive than chest X-ray in detecting intra-thoracic abnormalities such as pneumothoraces and pneumomediastinums. Pneumomediastinum detected by chest X-ray or "overt pneumomediastinum", raises the concern of possible aerodigestive tract injuries. In contrast, there is scarce information on the clinical significance of pneumomediastinum diagnosed by CT scan only or "occult pneumomediastinum". Therefore we investigated the clinical consequences of occult pneumomediastinum in our blunt trauma population.A 2-year retrospective chart review of all blunt chest trauma patients with initial chest CT scan admitted to a level I trauma centre. Data extracted from the medical records include; demographics, occult, overt, or no pneumomediastinum, the presence of intra-thoracic aerodigestive tract injuries (trachea, bronchus, and/or esophagus), mechanism and severity of injury, endotracheal intubation, chest thoracostomy, operations and radiological reports by an attending radiologist. All patients with intra-thoracic aerodigestive tract injuries from 1994 to 2004 were also investigated.Of 897 patients who met the inclusion criteria 839 (93.5%) had no pneumomediastinum. Five patients (0.6%) had overt pneumomediastinum and 53 patients (5.9%) had occult pneumomediastinum. Patients with occult pneumomediastinum had significantly higher ISS and AIS chest (p0.0001) than patients with no pneumomediastinum. A chest thoracostomy tube was more common (p0.0001) in patients with occult pneumomediastinum (47.2%) than patients with no pneumomediastinum (10.4%), as well as occult pneumothorax. None of the patients with occult pneumomediastinum had aerodigestive tract injuries (95%CI 0-0.06). Follow up CT scan of patients with occult pneumomediastinum showed complete resolution in all cases, in average 3 h after the initial exam.Occult pneumomediastinum occurred in approximately 6% of all trauma patients with blunt chest injuries in our institution. Patients who had occult pneumomediastinum were more severely injured than those who without. However, none of the patients with occult pneumomediastinum had aerodigestive tract injuries and follow up chest CT scans demonstrated their complete and spontaneous resolution.

Thromboelastography (TEG®) provides a functional evaluation of coagulation. It has characteristics of an ideal coagulation test for trauma, but is not frequently used, partially due to lack of both standardized techniques and normal values. We determined normal values for our population, compared them to those of the manufacturer and evaluated the effect of gender, age, blood type, and ethnicity. The technique was standardized using citrated blood, kaolin and was performed on a Haemoscope 5000 device. Volunteers were interviewed and excluded if pregnant, on anticoagulants or having a bleeding disorder. The TEG® parameters analyzed were R, K, α, MA, LY30, and coagulation index. All volunteers outside the manufacturer’s normal range underwent extensive coagulation investigations. Reference ranges for 95% for 118 healthy volunteers were R: 3.8-9.8 min, K: 0.7-3.4 min, α: 47.8-77.7 degrees, MA: 49.7-72.7 mm, LY30: -2.3-5.77%, coagulation index: -5.1-3.6. Most values were significantly different from those of the manufacturer, which would have diagnosed coagulopathy in 10 volunteers, for whom additional investigation revealed no disease (81% specificity). Healthy women were significantly more hypercoagulable than men. Aging was not associated with hypercoagulability and East Asian ethnicity was not with hypocoagulability. In our population, the manufacturer’s normal values for citrated blood-kaolin had a specificity of 81% and would incorrectly identify 8.5% of the healthy volunteers as coagulopathic. This study supports the manufacturer’s recommendation that each institution should determine its own normal values before adopting TEG®, a procedure which may be impractical. Consideration should be given to a multi-institutional study to establish wide standard values for TEG®.

Intracranial hemorrhage (ICH) is common in traumatic brain injury (TBI) and a major determinant of death and disability. ICH commonly increases in size and coagulopathy has been implicated in such progression. We investigated the association between coagulopathy diagnosed by routine laboratory tests and ICH progression.Subgroup post hoc analysis from a randomized controlled trial including adult patients with blunt severe TBI (Glasgow Coma Scale scoreor=8) and repeat computerized tomography scans in 48 hours. Coagulopathy was defined as international normalized ratioor=1.3, activated partial thromboplastin timeor=35, or platelet count (PLT)or=100 x 10/L any time in the first 24 hours. Progression was any size increase or new ICH. TBI-associated coagulopathy was investigated measuring soluble tissue factor (TF) and d-dimer.The ICH progressed in 37 of 72 patients (51%), in 80% if any abnormal laboratory test (coagulopathic patients) versus 36% in noncoagulopathic (p = 0.0004). Abnormal international normalized ratio (odds ratio [OR] = 4.09; 95% confidence interval [CI] = 1.29-12.95; p = 0.017), PLT (OR = 12.59; 95% CI = 1.52-108.57; p = 0.019), head Abbreviated Injury Scale (AIS) (OR = 1.82; 95% CI = 1.15-2.88; p = 0.011) were significantly associated with progression (univariate analysis). In a multiple logistic regression, only head AIS (OR = 1.81; 95% CI 1.10-2.98; p = 0.0198) and PLT (OR = 11.8; 95% CI = 1.38-101.23; p = 0.024) correlated with progression. All patients with abnormal partial thromboplastin time experienced progression. ICH progression carried a 5-fold higher odds of death; 32% with progression died versus 8.6% without. Age, head AIS, Injury Severity Score, and d-dimer were also associated with mortality. Tissue factor was not associated with progression or mortality.This study demonstrates an association between coagulopathy, diagnosed by routine laboratorial tests in the first 24 hours, with ICH progression; and ICH progression with mortality in patients with severe TBI. The causal relationship between coagulopathy and ICH progression will require further studies.

From the Department of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; and Canadian Forces Health Services, Toronto, ON, Canada. Address reprint requests to Jeannie L.Callum, BA,MD,FRCPC, CTBS, Transfusion Medicine and Tissue Banks, Sunnybrook Health Sciences Centre, B211, 2075 Bayview Avenue, Toronto, ON, Canada M4N 3M5. E-mail: jeannie.callum@sunnybrook.ca 0887-7963/09/$ see front matter © 2009 Published by Elsevier Inc. doi:10.1016/j.tmrv.2009.06.007 IN 2006 IN the Journal of Trauma, Drs Malone, Hess, and Fingerhut recommended the adoption of 1:1:1 resuscitation (red blood cells [RBC]/fresh frozen plasma [FFP]/platelet). They recommended that such a protocol “be fully developed and examined in a clinical trial.” In the meantime they recommended its use during the “early chaotic phase of resuscitation to standardize blood product support.” They also stated “it should also encourage blood banks to remove impediments to rapid blood product delivery,” citing an article recommending 4 new blood transfusion “services” for trauma patients: (1) thawed FFP; (2) component delivery based on an algorithm; (3) delivery of acute transfusion packages (5 RBC, 5 FFP, 2 pools of platelets); and (4) activation of a transfusionmedicine specialist. Since that time, there has been a flurry of retrospective studies examining the effect of formula-driven resuscitation on the outcomes of trauma patients. In this edition of Transfusion Medicine Reviews, Stansbury et al review the available literature on 1:1:1 resuscitation in trauma patients in detail. They presented a balanced view of this topic and their article should be read by all blood bankers at trauma hospitals, especially before the introduction of formula-driven massive transfusion protocols. Unfortunately, formula-driven care has not been subjected to a prospective, randomized clinical trial (RCT). This editorial will present the major pro and con arguments in the debate between these 2 camps and examine each argument's validity. The major issues are summarized in tabular form in Table 1. However, unfortunately, this argument will not be

Hypertonic saline (HS) is a promising fluid resuscitation therapy with the potential to reduce lung injury caused by severe trauma. The experimental evidence that HS has hemodynamic, anti-inflammatory, immunological, and neuroprotective properties and that it attenuates post-traumatic lung injury and multiple organ dysfunction syndrome (MODS) is undeniable. Laboratory evidence continues to accumulate to suggest that administration of HS affects cells, organs, and the neuro-humoral response to trauma, which affects both the innate and adaptive immunity. In contrast to the experimental findings, no clinical study to date has demonstrated that resuscitation of trauma patients with HS significantly reduces lung injury and MODS. Two recent clinical trials have confirmed that HS exerts similar hemodynamic, anti-inflammatory, and immunological effects as in experimental models. While it is possible that in humans such effects do not result in attenuation of post-traumatic lung injury and MODS, another explanation could be that no clinical study to date was powered to identify such clinical outcomes. An ongoing large, multicenter, randomized clinical trial across the USA and Canada is the first that is powered to determine whether resuscitation with a single dose of HS reduces post-traumatic lung dysfunction and consequently should become part of the resuscitation of severely traumatized patients.

Bleeding remains a major cause of morbidity and mortality in obstetrics and gynecology. A unique drug, recombinant factor VIIa (rFVIIa), has been introduced recently for the management of surgical bleeding. This novel application of a drug that was restricted to hemophilia treatment for over 10 years has generated intense interest among surgeons. This article reviews the importance of bleeding in obstetrics and gynecology, the characteristics of this drug, including side effects, and all the evidence available on rFVIIa use in obstetrics and gynecology. Expert commentary on rFVIIa is presented with recommendations on its clinical application. rFVIIa is a fascinating adjunct therapy that is undergoing rapid and extensive investigation. rFVIIa has the potential to change the current standards of hemorrhage care in surgical patients, including obstetrics and gynecology patients.

BACKGROUND: Significant variation exists across registries in the criteria used to identify patients with no chance of survival, with potential for profound impact on trauma center mortality. The purpose of this study was to identify the optimal case definition for the unsalvageable patient, for the purpose of exclusion from performance improvement (PI) endeavors. METHODS: Data were derived from the American College of Surgeons' Trauma Quality Improvement Program for 2012 to 2013. We proposed three potential case definitions for the unsalvageable patient: (1) no signs of life as determined by local providers (NSOL), (2) prehospital cardiac arrest (PHCA), and (3) a proxy definition (PROXY) based on presenting vital signs, defined as emergency department (ED) heart rate = 0, ED systolic blood pressure = 0, and Glasgow Coma Scale score motor component = 1. Case definitions were compared using standard predictive tests to determine specificity and positive predictive value (PPV) for in-hospital mortality. After the optimal definition was identified, hierarchical logistic regression was used to assess the impact of including unsalvageable patients on trauma center risk-adjusted mortality. The impact on trauma center performance was determined as change in outlier status and performance decile after exclusion of patients who met the optimal case definition. RESULTS: During the study period, 223,643 patients met inclusion criteria across 192 trauma centers. Overall in-hospital mortality was 7.2%. The PROXY definition had excellent PPV for death, with less than 1% of patients meeting the PROXY criterion surviving. By contrast, NSOL and PHCA had PPVs low enough such that many of these patients went on to live (33% and 10%, respectively). After exclusion of patients who met the PROXY definition, 7% of trauma centers changed performance decile. This change was greatest for patients with penetrating injury and shock, with change in performance decile at 23% and 33% of centers, respectively. CONCLUSION: The PROXY case definition has excellent predictive utility to identify patients who, based on presenting vital signs, will go on to die. PROXY should be used to exclude unsalvageable patients from PI endeavors. Language: en

BACKGROUND: Hemorrhage is the leading cause of preventable posttraumatic death. Many such deaths may be potentially salvageable with remote damage-control surgical interventions. As recent innovations in information technology enable remote specialist support to point-of-care providers, advanced interventions, such as remote damage-control surgery, may be possible in remote settings. METHODS: An anatomically realistic perfused surgical training mannequin with intrinsic fluid loss measurements (the “Cut Suit”) was used to study perihepatic packing with massive liver hemorrhage. The primary outcome was loss of simulated blood (water) during six stages, namely, incision, retraction, direction, identification, packing, and postpacking. Six fully credentialed surgeons performed the same task as 12 military medical technicians who were randomized to remotely telementored (RTM) (n = 7) or unmentored (UTM) (n=5) real-time guidance by a trauma surgeon. RESULTS: There were no significant differences in fluid loss between the surgeons and the UTM group or between the UTM and RTM groups. However, when comparing the RTM group with the surgeons, there was significantly more total fluid loss (p = 0.001) and greater loss during the identification (p = 0.002), retraction (p = 0.035), direction (p = 0.014), and packing(p = 0.022) stages. There were no significant differences in fluid loss after packing between the groups despite differences in the number of sponges used; RTM group used more sponges than the surgeons and significantly more than the UTM group (p = 0.048). However, mentoring significantly increased self-assessed nonsurgeon procedural confidence (p = 0.004). CONCLUSION: Perihepatic packing of an exsanguinating liver hemorrhage model was readily performed by military medical technicians after a focused briefing. While real-time telementoring did not improve fluid loss, it significantly increased nonsurgeon procedural confidence, which may augment the feasibility of the concept by allowing them to undertake psychologically daunting procedures.This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially., TAC 2015 : Annual Meeting of the Trauma Association of Canada, April 9-10, 2015, Calgary, Alberta

Previous work has been published on the experiences of high-resource setting physicians mentoring in low-resource environments. However, not much is known about what mentees think about their First World mentors. We had the opportunity to explore this question in an Afghan Army Hospital, and we believe this is the first time this has been studied.We conducted a pilot cross-sectional survey of Afghan health care providers evaluating their Canadian mentors. We created a culturally appropriate 19- question survey with 5-point Likert scores that was then translated into the local Afghan language. The survey questions were based on domains of Royal College of Physicians and Surgeons of Canada's CanMEDS criteria.The survey response rate was 90% (36 of 40). The respondents included 13 physicians, 21 nurses and 2 other health care professionals. Overall, most of the Afghan health care workers felt that working with mentors from high-resource settings was a positive experience (median 4.0, interquartile range [IQR] 4-4), according to CanMEDS domains. However, respondents indicated that the mentors were reliant on medical technology for diagnosis (median 5.0, IQR 4-5) and failed to consider the limited resources available in Afghanistan.The overall impression of Afghan health care providers was that mentors are appropriate and helpful. CanMEDS can be used as a framework to evaluate mentors in low-resource conflict environments.Des travaux ont déjà été publiés sur l’expérience des médecins de milieux favorisés en ressources qui font du mentorat dans des milieux défavorisés en ressources. Toutefois, on en sait relativement peu sur ce que pensent les pupilles de leurs mentors des pays industrialisés. Nous avons eu l’occasion d’explorer cette question dans un hôpital militaire afghan et nous croyons qu’il s’agit de la première fois que ce sujet est étudié.Nous avons réalisé un sondage pilote transversal auprès des professionnels de la santé afghans pour qu’ils évaluent leurs mentors canadiens. Nous avons créé un sondage culturellement approprié comportant 19 questions assorties d’échelles de Likert à 5 points, qui a ensuite été traduit en langue afghane locale. Les questions du sondage s’inspiraient des domaines des critères CanMEDS du Collège royal des médecins et chirurgiens du Canada.Le taux de réponse au sondage a été de 90 % (36 sur 40). Les répondants étaient : 13 médecins, 21 infirmières et 2 autres professionnels de la santé. Dans l’ensemble, la plupart des professionnels de la santé afghans ont estimé que de travailler avec des mentors provenant d’un milieu favorisé en ressources a été une expérience positive (médiane 4,0; intervalle interquartile [IIQ] 4–4), selon les domaines CanMEDS. Les répondants ont toutefois indiqué que les mentors se fiaient à la technologie médicale pour le diagnostic (médiane 5,0; IIQ 4–5) et négligeaient de tenir compte des ressources limitées accessibles en Afghanistan.L’impression globale des professionnels de la santé afghans a été que les mentors sont qualifiés et utiles. Les critères CanMEDS peuvent être utilisés comme cadre pour évaluer les mentors dans des zones de conflit où les ressources sont limitées.Des travaux ont déjà été publiés sur l’expérience des médecins de milieux favorisés en ressources qui font du mentorat dans des milieux défavorisés en ressources. Toutefois, on en sait relativement peu sur ce que pensent les pupilles de leurs mentors des pays industrialisés. Nous avons eu l’occasion d’explorer cette question dans un hôpital militaire afghan et nous croyons qu’il s’agit de la première fois que ce sujet est étudié.Nous avons réalisé un sondage pilote transversal auprès des professionnels de la santé afghans pour qu’ils évaluent leurs mentors canadiens. Nous avons créé un sondage culturellement approprié comportant 19 questions assorties d’échelles de Likert à 5 points, qui a ensuite été traduit en langue afghane locale. Les questions du sondage s’inspiraient des domaines des critères CanMEDS du Collège royal des médecins et chirurgiens du Canada.Le taux de réponse au sondage a été de 90 % (36 sur 40). Les répondants étaient : 13 médecins, 21 infirmières et 2 autres professionnels de la santé. Dans l’ensemble, la plupart des professionnels de la santé afghans ont estimé que de travailler avec des mentors provenant d’un milieu favorisé en ressources a été une expérience positive (médiane 4,0; intervalle interquartile [IIQ] 4–4), selon les domaines CanMEDS. Les répondants ont toutefois indiqué que les mentors se fiaient à la technologie médicale pour le diagnostic (médiane 5,0; IIQ 4–5) et négligeaient de tenir compte des ressources limitées accessibles en Afghanistan.L’impression globale des professionnels de la santé afghans a été que les mentors sont qualifiés et utiles. Les critères CanMEDS peuvent être utilisés comme cadre pour évaluer les mentors dans des zones de conflit où les ressources sont limitées.

Tension pneumothorax (TPTX) is a life-threatening condition and the third most frequent cause of preventable deaths on the battlefield.1 Autopsy studies from the Vietnam War suggested that TPTX led to 3%–5% of all potentially preventable deaths.2 The clinical definition of TPTX is a PTX that results in hemodynamic compromise, as the increased intrathoracic pressure interferes with the venous return to the right atrium. Viewed on chest imaging, lateral shift of the mediastinum concurrent with respiratory distress (or difficult ventilation) and/or hypotension is considered the hallmark of TPTX,3,4 even though obtaining a chest radiograph for suspected tension TPTX is considered an unjustified delay. The Advanced Trauma Life Support (ATLS) guideline proposed by the American College of Surgeons recommends that the diagnosis be made based only on clinical grounds. Tension PTX is caused by the progressive buildup of air within the pleural space, and positive pressure ventilation may accelerate this process, which may result in traumatic arrest. The ATLS recommends that needle thoracostomy should be performed at the second intercostal space (ICS) in the midclavicular line using a catheter more than 5 cm long.5 While the urgent evacuation of a patient with PTX is a component of all emergency medical algorithms,5 controversy remains regarding the optimal timing and means of treatment prior to evacuation. Some consider needle decompression (also called needle thoracostomy [NT]) as a temporary means for pressure release and bridging therapy until the insertion of a tube thoracostomy (TT). Others suggest that NT can sometimes be definitive therapy, and that not every NT should be followed by a TT insertion. Finally, some suggest TT, rather than NT, as the primary therapy.4,6,7 The reported success rates and the level of training required for these procedures vary.8 Prehospital NT can be life-saving, but technical aspects of the procedure have given rise to a discussion of whether it should be considered only a temporary measure. Investigators have reported chest wall thickness to be a key factor accounting for failures to successfully evacuate the chest, and therefore recommend the use of longer needles. Stevens and colleagues9 retrospectively examined thoracic computed tomography (CT) studies and determined the chest wall thickness at the midclavicular line to be 41–45 mm compared to the 14-gauge angiocatheter length of 4.5 cm. They concluded that the standard angiocatheter was likely to be unsuccessful in 50% of trauma patients on the basis of body habitus alone. Similar findings were reported raising the same concerns.10–12 In other reports, techniques such as cadaver dissection13,14 and ultrasonography15,16 were used to detect the penetration of catheters. On the basis of these findings, a recommendation for change was issued, and many prehospital organizations have adopted the use of longer catheters. Tactical Combat Casualty Care (TCCC) guidelines recommend “decompress[ing] the chest on the side of the injury with a 14-gauge, 3.25 inch (8.25 cm) needle/catheter.”17,18 The catheter’s diameter is another concern. Martin and colleagues19 used a porcine model to show that the decompression of the chest by a 14-gauge needle should not be expected to result in relief of tension physiology, as a substantial air leak necessary to cause TPX physiology cannot be effectively drained with a 14-gauge tube. The preferred NT insertion site itself is subject to debate, with evidence suggesting that the fourth and fifth ICS (at the anterior axillary line, similar to the recommended TT insertion site) may be superior to the classic site (the midclavicular line).12,14 Others raised concerns regarding the function of the NT inserted in this site, and both insertion site options are currently considered valid.4 Despite these and other concerns, the current recommended needle used for decompression is a 14-gauge angiocatheter.5 Owing to these considerations, along with concerns regarding catheter kinking20 and blockage, in 2006 the Israeli Defense Forces Medical Corps (IDF-MC) introduced a thicker, longer catheter for the performance of rapid chest decompression. We report our experience with NT and preliminary data on our use of a 10-French Vygon TT unit (thoracic trocar and drain; Vygon), instead of the traditional 14-gauge angiocatheter, as the preferred means for rapid chest decompression.

Medical support to deployed field forces is increasingly becoming a shared responsibility among allied nations. National military medical planners face several key challenges, including fiscal restraints, raised expectations of standards of care in the field and a shortage of appropriately trained specialists. Even so, medical services are now in high demand, and the availability of medical support may become the limiting factor that determines how and where combat units can deploy. The influence of medical factors on operational decisions is therefore leading to an increasing requirement for multinational medical solutions. Nations must agree on the common standards that govern the care of the wounded. These standards will always need to take into account increased public expectations regarding the quality of care. The purpose of this article is to both review North Atlantic Treaty Organization (NATO) policies that govern multinational medical missions and to discuss how recent scientific advances in prehospital battlefield care, damage control resuscitation and damage control surgery may inform how countries within NATO choose to organize and deploy their field forces in the future.De plus en plus, la responsabilité du soutien médical offert aux forces militaires déployées sur le terrain devient partagée entre les nations alliées. Les planificateurs médicaux militaires nationaux font face à plusieurs défis importants, tels que restrictions budgétaires, attentes élevées au chapitre des normes de soin sur le terrain et pénurie de spécialistes dûment formés. Malgré cela, les services médicaux sont présentement en grande demande et leur disponibilité pourrait devenir le facteur limitatif susceptible de déterminer de quelle façon et en quels lieux les unités de combat peuvent se déployer. L’impact des facteurs médicaux sur les décisions opérationnelles requiert donc de plus en plus des solutions médicales multinationales. Les nations doivent s’entendre sur des normes communes qui régissent les soins à prodiguer aux blessés. Ces normes devront toujours tenir compte des attentes accrues du public en regard de la qualité des soins. Le but de cet article est de revoir les politiques de l’Organisation du Traité de l’Atlantique Nord (OTAN) qui régissent les missions médicales multinationales et de discuter de la façon dont les progrès scientifiques récents des soins pré-hospitaliers sur les champs de bataille et les techniques de réanimation et de chirurgie de sauvetage peuvent éclairer la façon dont les pays de l’OTAN décideront d’organiser et de déployer leurs forces sur le terrain à l’avenir.

Literature is lacking on acute surgical problems that may be encountered on military deployment; even less has been written on whether or not any of these surgical problems could have been avoided with more focused predeployment screening. We sought to determine the burden of illness attributable to acute nontraumatic general surgical problems while on deployment and to identify areas where more rigorous predeployment screening could be implemented to decrease surgical resource use for nontraumatic problems.We studied all Canadian Armed Forces (CAF) members deployed to Afghanistan between Feb. 7, 2006, and June 30, 2011, who required treatment for a nontraumatic general surgical condition.During the study period 28 990 CAF personnel deployed to Afghanistan; 373 (1.28%) were repatriated because of disease and 100 (0.34%) developed an acute general surgical condition. Among those who developed an acute surgical illness, 42 were combat personnel (42%) and 58 were support personnel (58%). Urologic diagnoses (n = 34) were the most frequent acute surgical conditions, followed by acute appendicitis (n = 18) and hernias (n = 12). We identified 5 areas where intensified predeployment screening could have potentially decreased the incidence of in-theatre acute surgical illness.Our findings suggest that there is a significant acute care surgery element encountered on combat deployment, and surgeons tasked with caring for this population should be prepared to treat these patients.Il y a un manque de données sur les problèmes chirurgicaux aigus qui peuvent survenir lors de déploiements militaires, et encore moins sur la question de savoir si on aurait pu éviter ces problèmes en faisant un dépistage plus ciblé avant le déploiement. Nous avons tenté de déterminer le fardeau de la maladie attribuable à des problèmes non traumatiques aigus de chirurgie générale pendant le déploiement, puis d’identifier les domaines où un dépistage préalable plus rigoureux pourrait être mis en oeuvre pour réduire l’utilisation des ressources chirurgicales pour les problèmes non traumatiques.Notre étude a porté sur tous les membres des Forces armées canadiennes (FAC) déployés en Afghanistan entre le 7 février 2006 et le 30 juin 2011 et qui ont eu besoin de traitement pour un état chirurgical général non traumatique.Pendant la période de l’étude, 28 990 membres des FAC ont été déployés en Afghanistan; 373 (1,28 %) ont été rapatriés en raison de maladie et 100 (0,34 %) ont développé un état chirurgical général aigu. Parmi ces derniers, 42 faisaient partie du personnel de combat (42 %) et 58 faisaient partie du personnel de soutien (58 %). Les diagnostics urologiques (Il ressort de nos conclusions que les missions de combat comportent un important élément de soins chirurgicaux aigus et que les chirurgiens chargés de soigner cette population devraient être préparés à traiter ces patients.

Background Growing public concern for animal welfare, advances in computerized simulation and economic barriers have drawn a critical eye to the use of live tissue training (LTT) in trauma skills acquisition. As a consequence, other simulation methods have replaced LTT, for example, in the Advanced Trauma Life Support (ATLS) course. Owing to the lack of clear conclusions in the literature, we conducted a systematic review to determine the value of LTT alone and in comparison to other simulation methods in trauma.

Hemorrhagic shock following civilian trauma is an important contributor to the morbidity and mortality in this patient population.1 The body's early response to traumatic injury and hemorrhage is characterized by an excessive innate immune activation and by an overwhelming inflammatory reaction.2 Research findings suggest a strong link between immune dysfunction and post-traumatic complications such as multiorgan dysfunction (MOD) and sepsis.3–5 Regulated inflammatory responses are generally considered a beneficial host response to injury,6 while post-traumatic hyperinflammation and ensuing immune incompetence are considered to be maladaptive and often auto-destructive.2 One of the fundamental principles applied to the management of hemorrhagic shock is the early administration of fluid and blood products to correct the deranged hemodynamic status. Crystalloid solutions have generally been considered first-line therapy. However, recent evidence suggests that isotonic crystalloid solutions may actually aggravate the immune dysfunction.7 By contrast, a number of experimental studies reveal that hypertonic solutions have favorable immunomodulatory effects on hemorrhage/resuscitation-induced leukocyte activation.4,8–11 For example, data derived from both in vitro human leukocyte studies as well as animal models of hemorrhagic shock found that hypertonicity decreases neutrophil activation/adherence,12–16 stimulates lymphocyte proliferation,17 inhibits pro-inflammatory but stimulates anti-inflammatory cytokine production by monocyte/macrophages,8,18–22 and reduces hormone secretion.23,24 In the in vivo setting, hypertonic saline resuscitation strategies have been shown to mitigate the development of inflammation. When considered in conjunction with the ability of small-volume (4 mL/kg) infusion of hypertonic saline, to restore mean arterial pressure and microvascular perfusion25,26 as well as its proven safety record in patients,27,28 there has been renewed interest in the use of hypertonic saline solutions, with or without dextran in the management of patients with hemorrhagic shock.29–31 One critical piece of information lacking in the translation of these beneficial effects to the human trauma setting is whether hypertonic saline/hypertonic saline dextran (HS/HSD) is able to exert comparable immunologic effects in humans. The major objective of the present studies was to investigate the immunomodulatory effects of HSD in patients sustaining hemorrhagic shock following trauma. Without altering standards of treatment, patients were randomized to receive either a single 250-mL bolus of HSD or placebo. Blood drawn at subsequent time points was evaluated for a number of cellular and molecular inflammatory markers known to be altered by shock/resuscitation. We hypothesized that these markers would be altered in resuscitated trauma patients, in a manner previously reported in experimental models. These data were intended to provide “proof of principle” for larger trials that intended to study clinical outcomes with this resuscitation regimen.

Objective: Assess if the benefits outweigh the risks of intravenous (iv) contrast in trauma patients who present with an elevated serum creatinine (Cr). Background: Radiologic investigations with iv contrast are often used in trauma patients to rapidly assess for life threatening injuries. However, contrast nephropathy (CNP) is associated with increased morbidity and mortality. This poses a dilemma for the physician who must weigh the risks and benefits of proceeding with iv contrast versus the risks of missed injuries/delayed diagnosis. Methods: A 2 year (2002-2003) retrospective chart review of all trauma patients presenting with an elevated Cr(≥1.3 mg/dL or ≥115 μmol/L). Results are mean ± sd (p < 0.05 significant). Results: Ninety-five patients (age 51 ± 23 years; ISS 31.7 ± 15.6; hospital stay 29 ± 32 days; mortality 9%) presented with a Cr ≥ 1.3 mg/dL (31 with Cr ≥1.7; 3 dialysis dependent). Fifty-six (59%) were given iv contrast (C+), of which only 2 (3%) had a transient rise of 25% in Cr within 48 hours versus 6 (16%) patients not exposed to contrast (C-). No C+ patient developed CNP requiring longterm dialysis. Of the 56 undergoing C+ tests, 16 had injuries requiring urgent intervention identified; 16 had injuries that were managed nonoperatively, and 24 had serious injuries ruled out. Of the 39 C- patients, 9 had indeterminate CT's; 2 had missed injuries; and 2 had no intraabdominal injuries found at celiotomy. Conclusion: This study suggests the benefits may outweight the risks for proceeding prn with iv contrast in trauma patients with an elevated creatinine. A larger study is needed to confirm these findings.

The study of trauma deaths has been the driving force for developing regionalised trauma systems, has functioned as a method of auditing quality of care in trauma centres, and has identified areas for further research. The findings in contemporary trauma death studies reveal that the vast majority of trauma deaths are secondary to the severity of injury. Indeed, most trauma deaths now occur in the field or in the first few days of hospitalisation, and are from severe CNS injuries and great vessel injuries, and are deemed unpreventable. Late deaths are potentially preventable deaths, and still constitute an area where advances in therapy may result in improved trauma outcomes. Multiple organ failure is now the subject of intense and innovative research. Any dramatic change in trauma outcomes, however, will now likely occur as a result of aggressive efforts in injury prevention. Injury prevention strategies can hopefully modify behaviour such that these injuries do not occur.

Background Blunt traumatic diaphragmatic rupture (BTDR) occurs when signicant deceleration mechanism and energy are applied to the torso, and it is associated with signicant injuries and high morbidity and mortality. Although it has limitations, CT scan is the diagnostic of choice for BTDR. This study is a retrospective analyse of our experience in diagnosing BTDR using the 64-slice CT scanner. Sensitivity and specicity of this exam were assessed. Methods We reviewed reports from 2006 to 2009 of all CT scans of the abdomen that were done in the rst 24 hours of hospitalization of blunt trauma patients. We compared CT ndings to surgery reports. Results Our cohort consisted of 2670 patients; 69% were male. We found 28 cases of BTDR, most of them on the patient s left side (54%). Eleven percent of cases were bilateral. BTDR was often caused by motor vehicle collisions. We found sensitivity of 86%, specicity of 99%. Conclusion CT scan is reliable tool in blunt trauma patients. As new technologies arise, its sensibility and specicity also increases. How to cite this article Passos E, Nascimento B, Netto FS, Tien H, Rizoli S. The Role of CT Scan in Recognizing Blunt Diaphragmatic Rupture. Panam J Trauma Critical Care Emerg Surg 2012;1(1):24-26.

Background Transfusing packed red blood cells (PRBCs) into Special Forces may provide a survival advantage from hemorrhage-induced battlefield injuries; however, the effect of the unique operational stressors on RBC integrity is not known. Methods Pooled PRBCs (20 U) (7 days old), stored in Golden Hour containers, were exposed to the following simulated operational stressors: High-Altitude Low-Opening parachute descent from 30,000 ft, followed by a simulated soldier presence patrol in a climatic chamber set to 48 °C and 9% humidity for 12 hours (test). Biochemical (pH, lactate, potassium, and adenosine triphosphate) and biomechanical (percent hemolysis, deformability, and morphology) were measured to determine the integrity of PRBCs. Results The simulated parachute descent significantly raised pH (p = 0.025) and potassium (p = 0.014) levels compared with the control; however, this was not clinically significant. Lactate (mmol/L) and adenosine triphosphate levels (0 μmol/g Hgb) were unaffected (p > 0.05). Potassium and pH levels increased with time but not significantly compared with controls. Lactate levels were unaffected with time.Mechanical agitation of PRBCs from the simulated soldier presence patrol did not significantly affect the biochemical (p ≥ 0.08) or biomechanical (p ≥ 0.33) parameters compared with control.Hemolysis was found to be less than 0.8% at the end of 12 hours. No significant difference in RBC morphology and RBC deformability were noted. Conclusion Carrying PRBCs into the austere Special Forces environment is feasible as biochemical and biomechanical markers of RBC stress remain within published transfusion safety parameters when PRBCs were stored in new cold technology containers for 12 hours at 48°C during a simulated Special Forces operation.

Purpose of review This article reviews the latest operative trauma surgery techniques and strategies, which have been published in the last 10 years. Many of the articles we reviewed come directly from combat surgery experience and may be also applied to the severely injured civilian trauma patient and in the context of terrorist attacks on civilian populations. Recent findings We reviewed the most important innovations in operative trauma surgery; the use of ultrasound and computed tomography in the preoperative evaluation of the penetrating trauma patient, the use of temporary vascular shunts, the current management of military wounds, the use of preperitoneal packing in pelvic fractures and the management of the multiple traumatic amputation patient. Summary The last 10 years of conflict has produced a wealth of experience and novel techniques in operative trauma surgery. The articles we review here are essential for the contemporary care of the severely injured trauma patient, whether they are card for in a level 1 trauma center or in a field hospital at the edge of a battlefield.

Background Haemorrhage in peripheral vascular injuries may cause life-threatening exsanguination. Tourniquets are used extensively by the military, with increased interest in the civilian setting to prevent deaths. This is a retrospective study of trauma patients at two large Canadian trauma centres with arterial injury after isolated extremity trauma. We hypothesized that tourniquet use may decrease mortality rate and transfusion requirements if applied early. Methods The study group was all adult patients at two Level 1 Trauma Centres in two Canadian cities in Canada, who had arterial injuries from extremity trauma. The study period was from January 2001 to December 2010. We excluded patients with significant associated injuries. The intervention in this study was prehospital tourniquet use. The main outcome was in-hospital mortality. Secondary outcomes were length of stay, compartment syndrome, amputation, and blood product transfusion. Results 190 patients were included in the study, and only 4 patients had a prehospital tourniquet applied. They arrived directly from the scene of injury, had improvised tourniquets by police or bystanders, and showed a trend to be more hypotensive and acidotic. Four other patients had tourniquets applied in the trauma bay within 1 h of injury. There were no differences in age, sex, injury severity or physiologic presentation between patients who had an early tourniquet applied and those who died without a tourniquet. However, six patients died without a tourniquet, and all bled to death. Of the eight patients who had early tourniquets applied, none died. Conclusions Tourniquets may prevent exsanguination in the civilian setting for patients suffering either blunt or penetrating trauma to the extremity. Future studies will help determine the utility of deploying tourniquets in the civilian setting, given the rarity of exsanguinating haemorrhage from isolated extremity trauma in this setting.

To determine the best field tourniquet for Medical Technician (Med Tech) use in the Canadian Forces (CF).We conducted a prospective controlled trial, comparing the efficacy and ease of applicability of 3 types of commercially available windlass tourniquets in 4 tactical situations on simulated patients. The primary outcome was time to tourniquet application with secondary outcomes including effectiveness and Med Tech satisfaction.The overall finding of this study indicates that the Combat Application Tourniquet (C-A-T) was applied the fastest in each scenario and was also significantly the most effective in occluding distal blood flow. The survey results show that the 3 tourniquet types are similar in many of the measures of ease of learning and application, with the C-A-T scoring highest in self-application and the Special Operations Forces Tactical Tourniquet Wide having the lowest scores for both durability and effectiveness.When tested on a group of CF Med Techs, the C-A-T remained the CF field tourniquet of choice, based on the assessed criteria. Although there is inherent bias in the approach of this study, it reflects the process required to determine if a new piece of kit is superior to what is already considered the standard to a trained and equipped military.

Introduction: Helicopter emergency medical services (HEMS) have become an engrained component of trauma systems to expedite transportation to a trauma centre. Ornge is a provincially run, paramedic-staffed HEMS that is responsible for all air ambulance service within Ontario, Canada. They provide transportation for trauma patients through one of three ways: scene call, modified scene call or interfacility transfer. In this study we report the characteristics of patients transported by each of these methods to two level 1 trauma centres and assess for any impact on morbidity or mortality. Methods: A local trauma registry was used to identify all patients transported to our two trauma centres by HEMS over a 36-month period. Data surrounding patient demographic, arrival characteristics, transport times and in-hospital course were abstracted from the registry. Statistical analysis will be used to compare methods of transport and characterize any association between mode of transport and mortality. Results: From January 1st, 2012 to December 31st, 2014 HEMS transferred a total of 911 patients to our trauma centers with an overall mortality rate of 11%. Of these patients 139 were scene calls with a mortality rate of 8%, 333 were modified scene calls with a mortality rate of 14% and 439 were interfacility transfers with a mortality rate of 10%. Conclusion: Identifying any association between the type of HEMS transport and morbidity and mortality, we may be able to predict those that need more urgent transfer to a trauma centre and find ways to decrease our overall pre-trauma center time.

Background Venous thromboembolism (VTE) frequently complicates the recovery of trauma patients, and contributes to morbidity and mortality. Recent studies showed an increase in diagnosis of pulmonary embolism (PE) mainly in the early or immediate period after trauma. The clinical significance of those incidental PEs is unclear. Methods The study cohort included all blunt trauma patients who had a contrast-enhanced CT of the chest performed as part of their initial trauma assessment from January 1, 2005 to January 31, 2007 in a large academic Canadian trauma centre. Patients diagnosed with PE at any point during admission were identified using our institutional trauma registry. All chest CT scans and electronic charts were reviewed. Patients were classified according to time of PE detection (immediate, early or late) and symptoms (asymptomatic or symptomatic). The clinical characteristics and hospital course of the patients who were diagnosed with immediate PE were described. Results 1259 blunt trauma patients were reviewed. Six patients presented with immediate PE (0.5%); nine patients were found to have early PE (0.7%) and 13 had late PE (1.0%). All six of the patients with immediate PE were classified as asymptomatic. Five of the nine patients with early PE were symptomatic and all 13 patients who developed late PE were symptomatic. Amongst the six patients with immediate PE, five survived 24 h hospitalisation. Four of them were managed with prophylactic low molecular weight heparin and no other thromboembolic events were observed during admission or after discharge. Conclusions The increased use of advanced CT technology in trauma patients has resulted in an increased diagnosis of incidental PEs that are asymptomatic. The clinical significance and management of these small, incidental PE are uncertain and further studies are needed to clarify the natural history of this controversial finding.

The mission of the Canadian Forces Health Services (CFHS) is to provide full-spectrum, high-quality health services to Canada’s fighting forces wherever they serve.1 This obligation dates back to the Constitution Act of 1867, which assigned sole responsibility of all military matters, including health care, to the federal government.2 As a result, the Canadian Army Medical Corps (CAMC) was formed in July 1904 and initially consisted of 8 physicians and 36 orderlies.3 The CAMC expanded substantially during the 2 world wars and again during the Korean War. At its peak, the CAMC consisted of almost 35 000 military health care providers who cared for about 84 000 Canadian soldiers.3 The CAMC became the Canadian Forces Medical Services in 1959; in 1995 it united with the Dental Services under the Surgeon General as the CFHS.3 Canada’s combat engagement in Afghanistan, which just ended this past summer, was the largest Canadian military undertaking abroad since the Korean War.4 In addition, this mission represented the largest deployment of CFHS personnel and equipment since the Korean War.5 The CFHS deployed almost 200 of its personnel with each successive rotation to provide seamless, continuous care for Canadian Forces (CF) members from point of injury (or illness) in Afghanistan to rehabilitative care back in Canada. To fulfill its mission in Afghanistan, the CFHS had to overcome significant challenges. Defense budget cutbacks dating back to the mid-1990s seriously reduced available CFHS resources and personnel from levels maintained during the Korean War and Cold War era: 3 of 6 CF hospitals were closed within 2 years, and the number of military health care providers was reduced from 3000 to 2400.3 Furthermore, trauma care had become increasingly complex and centred on highly specialized trauma systems, hospitals and practitioners that were not a normal part of the Canadian military health care system.5 Despite these challenges, to support the combat mission in Afghanistan, the CFHS developed a comprehensive trauma system based around its trauma hospital — the Role 3 Multinational Medical Unit (R3MMU) at Kandahar Airfield. The hospital developed a reputation for providing outstanding care, and CF members have taken comfort in the motto “If you arrive alive, you will leave alive.”6 This article reviews the essential components of a modern trauma system and outlines the evidence that comprehensive trauma systems improve care to injury victims. It then traces the genesis of the current CF trauma system. Although the CF combat mission in Afghanistan has ended, this article argues why the established trauma system should continue to be the basis for providing medical/trauma support to CF members deployed on future missions.

The use of international normalized ratio (INR) to diagnose vitamin K-dependent coagulation factor (VitK-CF) deficiency in trauma has limitations (inability to predict bleeding and long turnaround times). Thromboelastography (TEG) assesses the entire coagulation process. With TEG, reaction time (TEG-R) is used to assess global coagulation factor activity and takes less than 10 minutes. We assessed the ability of TEG-R to detect VitK-CF deficiency in trauma, compared to the INR.A total of 219 trauma patients with INR, TEG, and all VitK-CF measured at admission were included. Demographics and laboratory tests, drugs, blood transfusions, and severity scores were analyzed. Specificity, sensitivity, positive predictive value (PPV), and negative predictive value (NPV) of INR (≥1.3 and ≥1.5) and TEG-R (8 min) to diagnose VitK-CF deficits (≤50%) were calculated. Secondary outcomes included time to INR and TEG results.Overall, TEG-R performed worse than INR. TEG-R had a sensitivity of 33% (95% CI, 16%-55%), specificity of 95% (95% CI, 91%-98%), PPV of 47% (95% CI, 23%-72%), and NPV of 92% (95% CI, 87%-95%). An INR of 1.5 or greater had a sensitivity of 67% (95% CI, 45%-84%), specificity of 98% (95% CI, 96%-99.7%), PPV of 84% (95% CI, 60%-97%), and NPV of 96% (95% CI, 92%-98%). An INR of 1.3 or greater also had better sensitivity, PPV, and NPV. For patients on warfarin, the times to INR results and TEG completion were 58 (±23) and 92 (±40) minutes (p=0.07), respectively. TEG-R was abnormal in only one patient on warfarin.Our study suggests that TEG-R is not superior at identifying VitK-CF deficiency compared to INR in trauma.

Vertebral artery injuries can be seen following trauma. Most traumatic vertebral artery injuries are limited to an intimal dissection. Rarely, transection of the vertebral artery can be seen with extravasation of hemorrhage into the surrounding soft tissues of the neck. Dural tears are rare in the setting of trauma. They are usually the result of penetrating trauma or severe blunt trauma. We present a case with both a vertebral artery transection and a dural tear. The combination of these lethal injuries resulted in extravasation of hemorrhage into the soft tissues of the neck, through the dural tear, and into the subarachnoid space of the cervical spine. The subarachnoid hemorrhage extended superiorly into the brain. The diagnosis was made by computed tomography (CT) and computed tomography angiography (CTA). The treatment of traumatic vertebral artery transections and dural tears are discussed.

Hemorrhagic shock is a leading cause of death in trauma patients. Surgical control of bleeding and fluid resuscitation with both crystalloid and blood products remain the mainstay of therapy for injured patients with bleeding. However, there has been a recent re-evaluation of transfusion practice. Both the fear of transmissible disease and the costs of transfusing blood products have led to increasingly restrictive transfusion practices. A small percentage of trauma patients require massive transfusion. These patients are complex and difficult to manage, and clinicians must act quickly to save them. There is little evidence to help guide clinical transfusion decisions in these patients. A rational approach to using blood products requires an understanding of the end points of resuscitation. Resuscitation with fluids and red cells is necessary to improve perfusion and oxygen delivery to tissues. Avoiding overtransfusion is key, however, because transfusion is also associated with significant risks. This trend toward reducing allogenic blood exposure will likely continue. New technologies that have the potential of reducing blood loss and transfusion requirements in trauma patients with massive bleeding are being developed, and similar old technologies are being reapplied.