University of Notre Dame, South Bend, IN, USA.
Soldier Recovery Brigade, National Capital Region, Walter Reed, MD, USA.
Mil Med. 2022 Oct 29;187(11-12):e1265-e1270. doi: 10.1093/milmed/usab461.
Hemorrhage is the leading threat to the survival of battlefield casualties. This study aims to investigate the types of fluids and blood products administered in prehospital trauma encounters to discover the effectiveness of Tactical Combat Casualty Care (TCCC) recommendations.
This is a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry with a focus on prehospital fluid and blood administration in conjunction with changes in the TCCC guidelines. We collected demographic information on each patient. We categorized receipt of each fluid type and blood product as a binary variable for each casualty and evaluated trends over 2007-2020 both unadjusted and controlling for injury severity and mechanism of injury.
Our original dataset comprised 25,897 adult casualties from January 1, 2007 through March 17, 2020. Most (97.3%) of the casualties were male with a median age of 25. Most (95.5%) survived to hospital discharge, and 12.2% of the dataset received fluids of any kind. Medical personnel used crystalloids in 7.4% of encounters, packed red blood cells in 2.0%, and whole blood in 0.5% with very few receiving platelets or freeze-dried plasma. In the adjusted model, we noted significant year-to-year increases in intravenous fluid administration from 2014 to 2015 and 2018 to 2019, with significant decreases noted in 2008-2009, 2010-2012, and 2015-2016. We noted no significant increases in Hextend used, but we did note significant decreases in 2010-2012. For any blood product, we noted significant increases from 2016 to 2017, with decreases noted in 2009-2013, 2015-2016, and 2017-2018. Overall, we noted a general spike in all uses in 2011-2012 that rapidly dropped off 2012-2013. Crystalloids consistently outpaced the use of blood products. We noted a small upward trend in all blood products from 2017 to 2019.
Changes in TCCC guidelines did not immediately translate into changes in prehospital fluid administration practices. Crystalloid fluids continue to dominate as the most commonly administered fluid even after the 2014 TCCC guidelines changed to use of blood products over crystalloids. There should be future studies to investigate the reasons for delay in guideline implementation and efforts to improve adherence.
出血是战场伤员生存的主要威胁。本研究旨在调查院前创伤中使用的液体和血液制品的类型，以发现战术战斗伤亡护理 (TCCC) 建议的有效性。
这是对国防部创伤登记处先前描述的数据集的二次分析，重点是院前液体和血液的使用情况，并结合 TCCC 指南的变化。我们收集了每位患者的人口统计学信息。我们将每种液体类型和血液制品的使用情况归类为每个伤员的二进制变量，并评估了 2007 年至 2020 年期间未调整和控制损伤严重程度和损伤机制的趋势。
我们最初的数据集包括 2007 年 1 月 1 日至 2020 年 3 月 17 日期间的 25,897 名成年伤员。大多数（97.3%）伤员为男性，中位年龄为 25 岁。大多数（95.5%）伤员存活至出院，12.2%的数据集接受了任何类型的液体。医务人员在 7.4%的情况下使用晶体液，在 2.0%的情况下使用浓缩红细胞，在 0.5%的情况下使用全血，很少有血小板或冻干血浆。在调整后的模型中，我们注意到从 2014 年到 2015 年和 2018 年到 2019 年静脉输液的显著逐年增加，而在 2008-2009 年、2010-2012 年和 2015-2016 年显著减少。我们没有注意到羟乙基淀粉的使用显著增加，但我们确实注意到在 2010-2012 年显著减少。对于任何血液制品，我们注意到从 2016 年到 2017 年的显著增加，从 2009-2013 年、2015-2016 年和 2017-2018 年的减少。总的来说，我们注意到 2011-2012 年所有用途的普遍飙升，然后在 2012-2013 年迅速下降。晶体液的使用一直超过血液制品。我们注意到所有血液制品从 2017 年到 2019 年呈小幅上升趋势。
TCCC 指南的变化并没有立即转化为院前液体管理实践的变化。晶体液继续占据主导地位，即使在 2014 年 TCCC 指南改变为使用血液制品而不是晶体液之后也是如此。应该有未来的研究来调查指南实施延迟的原因，并努力提高依从性。
