Review of Tactical Medical Articles

Here is a link to reviews of tactical medical literature. None are current, but if one is interested in peer-reviewed articles, these are a good start.

Review of the Tactical Medical Literature

By: Tripp Winslow, MD MPH

In the medical literature, there is a paucity of peer-reviewed articles regarding Tactical Emergency Medical Services (TEMS). The majority of TEMS based articles are reviews of extrapolated EMS, Trauma, or Emergency Medicine literature. While these review articles are informative and promote awareness of TEMS as a specialty, it is evident that a greater effort must be made to advance the science and evidence based literature available for use in the field. In this journal scan identifying existing TEMS literature, I have summarized a few review articles and presented several original research papers as well. This review was carried out on PubMed. The bibliographies of all articles were reviewed for additional relevant articles.

LINK

Lessons Learned: “Four Hours of Tourniquet Time”

Below is an excerpt from a lessons learned compilation titled “First to Cut: Trauma Lessons Learned in the Combat Zone.” Though it is geared toward FST surgeons and forward medical providers, some of the lessons are applicable to tactical medics and mountain rescue. The larger take-away point is that the physiology occurring distally to a tourniquet applied for a long duration needs to be considered when changing or loosening, especially in environments where medical care may be limited (e.g., Third World).

    “Four Hours of Tourniquet Time”

    “26 y.o. male with foot traumatic amputation and
    multiple frag wounds to the right leg with a high thigh
    field tourniquet in place. Arrived to the CSH with SBP of
    100 HR of 120. we had no report on duration of the
    tourniquet. We took down the tourniquet and he promptly
    coded. We put the tourniquet back up, intubated him and
    gave him fluid and bicarb and he came back. We found
    out later that the tourniquet had been in place for over 4
    hours….”

    The use of tourniquets – while rare in civilian trauma is
    very common in combat injuries. Tourniquets are the
    number 1 instrument that a medic can employ to lower the
    KIA numbers. The use of tourniquet with application until
    the absence of a distal pulse by default causes distal
    ischemia. Release of a functioning tourniquet after several
    hours can result in the release of acidic fluid and potassium.
    The patient intubated and without a head injury can be
    briefly hyperventilated. Before taking down a long
    duration tourniquet make sure the patient is well hydrated,
    resuscitated, adding an ampule of sodium bicarbonate or
    THAM can prophylax against the release of “bad humors”,
    lactic acid, and potassium. Also release the tourniquet
    slowly – if the rare arrhythmia arises re–employ the
    tourniquet and retry after further bicarb and fluid. If the leg
    is necrotic remember “life before limb” and perform an
    amputation.

    Lessons Learned:
    –Prolonged tourniquet times can result in the release
    of acidotic fluid and hyperkalemia
    –Perform 4 compartment fasciotomy with all lower
    extremities with significant tourniquet times

Three-Step Cric?

Below you will find an article published in Military Medicine. It argues that traditional ways of providing a surgical airway in a tactical environment are flawed. Therefore, the authors continue, a new approach is needed. Three-step Cric

Objective: Surgical cricothyroidotomy is the airway of choice in combat. It is too dangerous for combat medics to perform orotracheal intubation, because of the time needed to complete the procedure and the light signature from the intubation equipment, which provides an easy target for the enemy. The purpose of this article was to provide a modified approach for obtaining a surgical airway in complete darkness, with night-vision goggles. Methods: At our desert surgical skills training location at Nellis Air Force Base (Las Vegas, Nevada), Air Force para-rescue personnel received training in this technique using human cadavers. This training was provided during the fall and winter months of 2003-2006. Results: Through trial and error, we developed a “quick and easy” method of obtaining a surgical airway in complete darkness, using three steps. The steps involve the traditional skin and cricothyroid membrane incisions but add the use of an elastic bougie as a guide for endotracheal tube placement. We have discovered that the bougie not only provides an excellent guide for tube placement but also eliminates the use of additional equipment, such as tracheal hooks or dilators. Furthermore, the bevel of the endotracheal tube displaces the cricothyroid membrane laterally, which allows placement of larger tubes and yields a better tracheal seal. Conclusion: Combat medics can perform the three-step surgical cricothyroidotomy quickly and efficiently in complete darkness. An elastic bougie is required to place a larger endotracheal tube. No additional surgical equipment is needed.