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Hemorrhage Control on the Battlefield

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Prehospital application of hemostatic agents in Iraq and Afghanistan.
Schauer SG, April MD, Naylor JF, Maddry JK, Arana AA, Dubick MA, Fisher AD, Cunningham CW, Pusateri AE.
Prehosp Emerg Care. 2018 Sep-Oct;22(5):614-623

Rationale for inclusion: Reviewed use of hemostatics between 2007-2016 (kaolin- Quikclot, chitosan- Hemcon and Celox). Patients receiving hemostatic agent- higher ISS, more likely to suffer GSW, higher AIS for abdomen and extremity. No difference in mortality.

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The effect of prehospital transport time, injury severity, and blood transfusion on survival of US military casualties in Iraq.
Kotwal RS, Scott LLF, Janak JC, Tarpey BW, Howard JT, Mazuchowski EL, Butler FK, Shackelford SA, Gurney JM, Stockinger ZT
J Trauma Acute Care Surg. 2018 Jul;85(1S Suppl 2):S112-S121.

Rationale for inclusion: Data from OIF, prehospital blood transfusion and battlefield survival.

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Recent advances in austere combat surgery: Use of aortic balloon occlusion as well as blood challenges by special operations medical forces in recent combat operations.
Northern DM, Manley JD, Lyon R, Farber D, Mitchell BJ, Filak KJ, Lundy J, DuBose JJ, Rasmussen TE, Holcomb JB
J Trauma Acute Care Surg. 2018 Jul;85(1S Suppl 2):S98-S103

Rationale for inclusion: Largest review of REBOA in far forward DCR. 19/20 were successful.

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Intramuscular tranexamic acid in tactical and combat settings.
Vu EN; Wan WCY; Yeung TC; Callaway DW.
Journal of Special Operations Medicine. 18(1):62-68, Spring 2018.

Rationale for inclusion: Support for TXA in the combat and tactical setting.

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Association of Prehospital Blood Product Transfusion During Medical Evacuation of Combat Casualties in Afghanistan With Acute and 30-Day Survival.
Shackelford SA, Del Junco DJ, Powell-Dunford N, Mazuchowski EL, Howard JT, Kotwal RS, Gurney J, Butler FK, Gross K, Stockinger ZT.
JAMA. 2017 Oct 24;318(16):1581-1591.

Rationale for inclusion: Data from OEF, prehospital blood transfusion and battlefield survival.

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Junctional hemorrhage control for tactical combat casualty care
Kotwal RS; Butler FK Jr.
Wilderness & Environmental Medicine. 28(2S):S33-S38, 2017 Jun.

Rationale for inclusion: Reviews studies on different junctional tourniquets available.

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Lessons learned for the resuscitation of traumatic hemorrhagic shock.
Spinella PC; Perkins JG; Cap AP.
US Army Medical Department Journal. (2-16)37-42, 2016 Apr-Sep.

Rationale for inclusion: Early hemostatic resuscitation with blood, minimize crystalloids. Permissive hypotension but NOT for prolonged field care. Coagulopathy is frequently present early after trauma. Over-resuscitation with crystalloid has significant complications. 

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Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom: increased plasma and platelet use correlates with improved survival.
Pidcoke HF; Aden JK; Mora AG; Borgman MA; Spinella PC; Dubick MA; Blackbourne LH; Cap AP.
The Journal of Trauma and Acute Care Surgery. 73(6 Suppl 5):S445-52, 2012 Dec.

Rationale for inclusion: Reviewed patients who received transfusion (2003-2012). Evaluate impact of updated CPGs. Decreased mortality with balanced transfusion. Support benefits of DCR, suggests platelet dysfunction may contribute to coagulopathy.

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Survival with emergency tourniquet use to stop bleeding in major limb trauma.
Kragh JF Jr, Walters TJ, Baer DG, Fox CJ, Wade CE, Salinas J, Holcomb JB.
Ann Surg. 2009 Jan;249(1):1-7.

Rationale for inclusion:  This is a relatively large study on the use of tourniquets in a combat hospital. The results are striking in that tourniquet use when applied early (before evidence of shock) was associated with survival in 90% versus 10% when applied in those already in shock.

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QuikClot use in trauma for hemorrhage control: case series of 103 documented uses.
Rhee P, Brown C, Martin M, Salim A, Plurad D, Green D, Chambers L, Demetriades D, Velmahos G, Alam H.
J Trauma. 2008 Apr;64(4):1093-9.

Rationale for inclusion: This is unique study in that both military and civilian, surgeons and pre-hospital providers used Quickclot for hemorrhage control in over 100 cases. It was found to effective, especially in the pre-hospital setting. Only 3 cases of burns were encountered.

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Practical use of emergency tourniquets to stop bleeding in major limb trauma.
Kragh JF Jr, Walters TJ, Baer DG, Fox CJ, Wade CE, Salinas J, Holcomb JB.
J Trauma. 2008 Feb;64(2 Suppl):S38-49; discussion S49-50.

Rationale for inclusion: This study on tourniquet use on combat injured patients provides data that supports very minimal morbidity associated with tourniquet use including nerve palsy and no limb loss due to tourniquet use in this study. 

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Prehospital tourniquet use in Operation Iraqi Freedom: effect on hemorrhage control and outcomes.
Beekley AC, Sebesta JA, Blackbourne LH, Herbert GS, Kauvar DS, Baer DG, Walters TJ, Mullenix PS, Holcomb JB; 31st Combat Support Hospital Research Group.
J Trauma. 2008 Feb;64(2 Suppl):S28-37; discussion S37.

Rationale for inclusion:  This is another study on tourniquet use at a combat hospital that further supports the use of tourniquets to aid in hemorrhage control in extremity injuries. No adverse outcomes were cited, and tourniquet use might have positively impacted potentially preventable deaths.

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Hemorrhage control in the battlefield: role of new hemostatic agents
Alam HB; Burris D; DaCorta JA; Rhee P.
Military Medicine. 170(1):63-9, 2005 Jan.

Rationale for inclusion: Lethal hemorrhage not amenable to compression or tourniquet can be addressed with hemostatic agents. Brief history of origin of hemostatic agents. Chitosan (Poly-N-acetyl glucosamine); Hemcon. Human fibrin dressing. Mineralized Zeolite (original Quikclot)- exothermic reaction.

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Tourniquets for hemorrhage control on the battlefield: a 4-year accumulated experience.
Lakstein D, Blumenfeld A, Sokolov T, Lin G, Bssorai R, Lynn M, Ben-Abraham R.
J Trauma. 2003 May;54(5 Suppl):S221-5.

Rationale for inclusion:  This study utilizes data that mostly pre-dates the US involvement in the Iraq and Afghanistan. The Israeli Defense Forces provide data supporting tourniquet use by pre-hospital medical and non-medical personnel as means of hemorrhage control in those with exsanguinating extremity wounds.

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