Rhabdomyolysis in the Tactical Enviroment

Rhabdomyolysis (Rhabdo for short) secondary to a combination over exertion and dehydration is gaining attention in exercise circles due to documented cases recently with the increasingly popular high-intensity workout regimens. The threat of Rhabdo is not only confined to the the gym. It ought to be planned for and considered in the tactical environment as well. It is not a concern in the Care Under Fire stage of care, but, as Schwartz, et. al. note in Tactical Emergency Medicine, it ought to be addressed during tactical en route care. In addition to being caused by exertion and dehydration, Rhabdo and the subsequent renal failure my be secondary to a crush injury in the tactical environment. However, this brief essay assumes that crush injuries will tip-off care providers to included Rhabdo in their differential diagnosis. Rhabdo due to exertion may not, however, be as apparent.

Essentially, Rhabdomyolysis is the release of myoglobin into the blood stream, which damages the kidneys in two ways: 1) physically blocking the nerphrons with myoglobin; 2) chemotoxic toxification. While this can only be definitively determined by a lab test at a higher echelon of care, it is beneficial to keep this in mind. For instance, in a disaster situation or MCI, an operator may exert himself and present with acute muscle pain and local edema. It has been shown that the level or exertion required for the Rhabdo is dependent on individual fitness. In fact, as little as 50 sit-ups a day for 5 consecutive days led to a case. Studies of NYC Firemen have shown that there is an inverse relation between risk or Rhabado and fitness level. Therefore, risk is difficult to determine as a group and needs to be considered with patient history in mind.

In addition to exertion, non-exercise risk factors can combine to increase the chance of occurrence. For instance, metabolic myopathies and Malignant Hyperthermia, both of which can be inherited, may increase risk when combined with nominal exertion. Furthermore, viral illness such as Epstien-Barr, herpes simplex, and parainfluenze may increase risks. Finally, the US Army has shown a 200-fold increase in risk in those with sickle cell traits.

While medics in the tactical environment may not have the capabilities to diagnose Rhbado, they can manage it if the patient’s exam leads one to believe it is an issue. However, only 50% of patients present with the classic signs of myalgias, tenderness or swelling of muscles, dark urine. Therefore, if a medic suspects Rhabdo, s/he needs to treat the acute risk of damage to renal tubes. To do so, it is suggested that one needs to use a saline infusion producing an ideal urine output of 200 ml/h. Of course, drugs and buffering with alkalization is optimal, but that is beyond the scope of most medics, and it is probably not needed for support during transport to higher medical care.

The best treatment is, as always, prevention in the tactical environment where resources are precious and limited. Risk ought to be mitigated by ensuring members of your team are in good shape. If they posses any of the listed non-exertional risks, they need to be instructed to use caution when performing tasks and operations.

For more detailed information, see this paper: Rhabdo_Military_Pers.

Update on Tactical Medicine Concepts and Controversies

We are pleased to announce an upcoming educational opportunity. On Thursday, October 14, 2010, the Texas Health Presbyterian Hospital will be hosting a conference titled, “Update on Tactical Medicine Concepts and Controversies.” This is a great opportunity and we will be attending.

Tactical_Medicine_Web_Brochure

Conference Description:
This conference will address those new and innovative interventions, products and techniques whose implementation at the point of wounding (POW) will allow for a more stable and viable patient upon arrival at the tertiary facility and, hence, improved longterm outcome. Though originally designed for the military theater, Tactical Combat
Casualty Care (TCCC) concepts are rapidly being adopted within the civilian medical and law enforcement communities as they are asked to respond to terror incidents at home. Columbine High School, Virginia Tech and terror incidents in Russia and India are only a few examples of the world in which we live. This conference is as relevant to
law enforcement (local and federal) and medical first responders as it is to the Soldiers and Marines on the battlefield. It is also relevant to physicians, nurses and other care providers, both civilian and military, who have a need for familiarity with current medical care techniques in the tactical environment.

Hemostaic Primer

We often get questions regarding hemostaics:
Which is the best?
How do they work?
What is the mechanism of action?

The TCCC recommendation of Combat Gauze (TM) has clouded the issue of effectiveness with respect to other available agents. That is to say, there are others on the market that were just as effective in studies that were not chosen. Hopefully, the attached study summarizes the pros and cons of most available agents.

TCCC Hemostatics JRAMC 2010

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

Contest Winner Announcment

After reviewing the many submissions for our first contest, 101 Ways to Use a Triangular Bandage, we have selected our winners. Due to the fact that two contestants submitted outstanding submissions, we decided to award two prizes. Our first winner, for the shear volume of ideas, is Lee Whitehead and he will receive $200 worth of Tac Med Gear. Our second winner, who submitted the most unique ideas that range from medical uses to survival, comes to us from Belgium (name withheld for OPSEC), and he will receive the same prize.

Thank you all for your submissions. We will begin posting videos of them over the next few months. If you have any other ideas for contests, let us know.

Tac Med Team

Chest Decompression for Non-Medics

Chest decompression for non-medics is a sticky subject. Recent observations overseas have seen an increase in improper location medially when inserting the needle. The causes of the high rate of improper placement are difficult to determine (i.e., environment, visibility, etc.) and have led to some medical directors prohibiting the procedure for non-medics within the military and LEO teams. However, the below study illustrates that proper initial training leads to high retention rates, thereby making this a skill that ought to remain at the operator level.

Abstract
Introduction: Tension pneumothorax is the second leading cause of preventable combat death. Although relatively simple, the management of tension pneumothorax is considered an advanced life support skill set. The purpose of this study was to assess the ability of non-medical law enforcement personnel to learn this skill set and to determine long-term knowledge and skill retention.

Methods: After completing a pre-intervention questionnaire, a total of 22 tactical team operators completed a 90-minute-long training session in recognition and management of tension pneumothorax. Post-intervention testing was performed immediately post-training, and at one- and six-months post-training.

Results: Initial training resulted in a significant increase in knowledge (pre: 1.3 ±1.35, max score 7; post: 6.8 ±0.62, p < 0.0001). Knowledge retention persisted at one- and six-months post-training, without significant decrement. Conclusions: Non-medical law enforcement personnel are capable of learning needle decompression, and retain this knowledge without significant deterioration
for at least six months.

Needle DC for Non-Medics

Contest: 101 Ways to Use a Trianguler Bandage

In an age when hemostatic agents and pocket-sized BP cuffs monopolize most conversations regarding combat casualty care, a command of the basics is being lost. While the abundance of choices of pre-made kits addressing the majority of field-treatable injuries reduces the chance of needing to improvise, one ought to have a command of the basics using available materials.

A medic cannot have a more basic piece of kit than a triangular bandage. Therefore, we are having a contest to encourage submissions of different ways to use a triangular bandage to treat combat trauma. The details are as follows:

Prize: $200 in free Tac Med gear

Submission Format: Either submit a description to the comments section or email them to alan@tacmedsolutions.com. How-to videos are welcomed, but not required. We will be filming the most unique and helpful techniques for the blog.

Deadline: All submission must be in by 1 MAR 2010. We will announce the winner by 15 MAR 10. Due to concerns with operational anonymity, we will request your approval before sharing your name.

How to Build a Personal First-Aid Kit

Below is an article from the latest Journal of Special Operations Medicine. It is an even-handed review of considerations when one is building a personal medical kit. It not only applies to SOF Operators, but to patrol officers and SWAT teams as well.

Individual Medical Equipment Part 1

Equipment Considerations: Level 3

We have thus far discussed considerations for packing Level 1 and Level 2 equipment. Remember that Level 1 gear is what you carry on your person (e.g., IFAKs and Med Vests) and Level 2 gear is carried in your first-aid bag. Level 3 gear is generally considered kit stored on your vehicle or supplement packs pre-positioned on resupply platforms. For instance, you might want to store the following on your vehicle:

1) pre-made IV kits
2) hypothermia prevention kits
3) backboards, rigid litters, evacuation prep kits
4) splinting material

With regard to pre-made bundles on resupply vehicles, it is a good idea to meet with helicopter crews that are supporting you, or the QRF, and ask to have numbered pre-made bundles for which you can call. For example,specific hemorrhage control items in a bag they can kick out the door, or a whole pre-packed aid bag. The latter can be be a bad idea, because you could find yourself with extra gear you don’t need and can’t store.

In the end, you must pack for your needs and trust your skills to make due with what you have, lest you find yourself imitating a pack mule.