Cord Cunningham, MD, MPH Lieutenant Colonel, US Army 1 st Air Cav Flight Surgeon EMS Physician

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1 Cord Cunningham, MD, MPH Lieutenant Colonel, US Army 1 st Air Cav Flight Surgeon EMS Physician

2 Opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the Department of the Army or the Department of Defense. No conflicts except my concern and drive to reduce prehospital/battlefield morbidity & mortality

3 Deep dive into the clotting cascade An airway talk Stand alone or comprehensive solution/reference applicable in its entirety to every EMS/Trauma system

4 Explore the Army implementation of Damage Control Resuscitation Understand The National Academy of Sciences recent Zero Preventable Trauma Deaths report and its implications to both military and civilian trauma systems Introduce the transition of the Army from Forward Surgical Teams to Forward Resuscitative Surgical Teams Discuss Military programs of Fresh Whole Blood transfusion, TXA, Freeze Dried Plasma, & REBOA and future concepts of prehospital DCR

5 Prehospital DCR is important Lethal Triad understanding Aspects of DCR are applicable to civilian EMS

6 About me What is Damage Control Resuscitation(DCR) DCR Importance Zero Preventable Deaths Hemorrhage Control Lethal Triad Ranger O-Low Titer Massive Transfusion Forward Resuscitative Surgical Team Conclusion/Discussion

Board Certified Emergency Physician 1 of 5 Active Army EMS Subspecialty Board Certified 5 Deployments to Iraq/Afghanistan with 75 th Ranger Regiment & USSOCOM

7 Board Certified Emergency Physician 1 of 5 Active Army EMS Subspecialty Board Certified 5 Deployments to Iraq/Afghanistan with 75 th Ranger Regiment & USSOCOM Medical Director of 15 Air Ambulance Unit and Fort Hood MSTC Involvement in many DoD Prehospital initiatives CoERCCC, MHS Genesis, medical monitor FDP & USAISR CCC research

8 Don t get dead(create another cax) Make the blood go round & round Make the air go in and out Treat pain and ease suffering Hand off better than you found it

9 Damage control resuscitation comprises early hemorrhage control, hypotensive resuscitation (permissive hypotension), hemostatic(balanced) resuscitation(minimization of crystalloid fluids and fixed ratio blood product transfusion), prevention or alleviation of hypothermia (through warming measures), and amelioration of acidosis through judicious use of blood products and hemodynamic resuscitation endpoints. Stopping hemorrhage and addressing the lethal triad, reducing massive transfusion, improving survival. Temporizing but critical

5000 4500 4000 3500 3000 2500 2000 1500 1000 500 0 976 3040 Pre-MTF Deaths MTF 287 271 Deaths Potentially Survivable

Death on the battlefield (2001-2011): implications for the future of combat casualty care. Journal of Trauma, 2012.

10 Pre-MTF Deaths MTF Deaths Potentially Survivable Non-Survivable Eastridge BJ, Mabry RL, Seguin PG, et al. Death on the battlefield ( ): implications for the future of combat casualty care. Journal of Trauma, Eastridge BJ, Hardin M, Cantrell J, et al. Died of wounds on the battlefield: causation and implications for improving combat casualty care. Journal of Trauma, (Suppl 1):4-8.

12 Overarching 11 rec paper #1-White House set aim of zero SECDEF holds COCOMs and DHA accountable ACS, NHTSA, & NAEMSO collaboration with HHS/DoD Focus on 1-2 big initiatives a yr Develop and maintain expertise

13 Surgeon General of UK Armed Forces Described cycle of improving trauma cax care during war and then losing that expertise inter war only to relearn it again Displayed in every US War from Civil War on Our challenge to avoid the Dip

14 Zone 1-Extremity Zone 2-Junctional Zone 3-Truncal

15 Immediate direct pressure and early hasty tourniquet (high & tight) Use of TQ prior to shock 90% improvement in survival vs after shock No permanent sequelae < 3hr and unlikely < 6hrs CATs on every FD/EMS/PD Hartford Consensus Stop the Bleed

16 SJT CRoC JETT AAJT

17 Kaolin-inert clay type material promotes clotting Chitosan-derived from crustacean shells and promotes congealing of RBC/platelets independent of factors Mechanical/Expansive

18 Considered not externally compressible(aajt??) REBOA(ER-REBOA 7 fr) Field Thoracotomy Foam(testing) Leads to lethal triad

19 J Trauma 2011

20 Coagulopathy Acidosis Hypothermia

21 Disruption/dilution/imbalance of some aspect of the clotting cascade Addressed prehospital via TXA, FDP, PRBCs, & FWB

22 Antifibrinolytic by competitive inhibition at multiple plasminogen sites decreasing fibrin formation Cyclokapron IV FDA approved for dental procedure bleeding prophylaxis in hemophiliacs and bleeding post CABG

23 CRASH-2 & MATTERs < 1hr, 1-3hr, >3hr No proven benefit in IC bleed Administration Slow IV push 1 min(hypotension) Filter needle(glass) Potential for readministration

DoD(USASOC) as part of FDA IND for French FDP US Army Medical

24 Current-French product from pooled donors, glass bottle, reconstituted before administration Experimental protocol for DoD(USASOC) as part of FDA IND for French FDP US Army Medical Material Development Activity by 2020 US product(us plasma, plastic bag)

26 Carry of PRBC s on MEDEVAC Conventional use began in RC South AFG in 2012(EMT) Despite expansion still only in CENTCOM 1 u PRBC, 1 u FFP currently

27 5 KIA in 50 receiving PRBCs 75 KIA in 267 without Unadjusted p=.007

28 May 2015 screening initiated O type consented TTD and IgM TTD and IgM < 256 ID d Retested annually and counseled on safe practices Mar 2016 first txfn 3 cases(4u s) to date(predrawn) Boundtree/Chinook sets draw with 14/16ga and no Y line

29 Prehospital shock index HR/SBP predicts massive transfusion(mt) (Vandromme et al., 2011) McLaughlin et al identified HR, SBP, ph, Hct as predictors of MT(HR > 105 OR 4.8) Use of the ABC(assessment blood consumption) score BP, HR, penetrating truncal injury and positive FAST to predict MT(Nunez et al) ABC 2 75% sens 86% sp PROMMTT Study(Holcomb et al) 3 u -1/1 Transient prehospital hypotension but normal in ED(Lipsky et al) 3 x Are Red/Blue Major/Minor trauma criteria enough to predict MT

30 Metabolic cellular demand and waste production exceeds supply and CV carrying capacity(shock) Balanced fluid resuscitation, identification/monitoring, hypovolemia, hypoxemia, hypercarbia

31 Tissue oxygenation ETCO2 CRI VBG/Lactate/BE-

32 Independent contributor to coagulopathy/increased metabolism Balanced with exposure for assessment and intervention Can occur even in hot environments (HPMK and vehicle heat)

33 FST 10 / 0 / 10 // 20 Medical Team, Forward Surgical Team (Current) GR MOSLN NO O5 61J00 1 O4 61J00 2 O4 61M00 1 O4 66S00 1 O3 66E00-OR 1 O3 66F00 2 O3 66T00 1 O2 70B67 1 E7 68W40 1 E6 68D30 1 E5 68D20 1 E5 68C20 1 E5 68W20 1 E4 68D10 1 E4 68C10 2 E4 68W10 1 E3 68W10 1 FRST 13 / 0 / 7 // 20 Medical Team, Forward Resuscitative and Surgical Team GR MOSLN NO O5 61J00-Surg 1 O4 61J00 1 O4 61M00-Ortho 2 O4 66S00-CCRN 1 O3 66S00 1 O3 66T00-ER RN 2 O3 66F00-CRNA 2 O3 62A00-EP 2 O2 70B67-MSC 1 E7 68W40-EMT 1 E6 68D30-OR 1 E5 68W20-EMT 2 E5 68C20-LPN 1 E5 68D20 1 E4 68C10 1 Complete FRST, provides emergency treatment to receive, triage, and prepare 30 incoming casualties for surgery over a 72 hour period and postoperative care can manage 8 patients over 6 hours post-surgery. Two resuscitative and surgical elements, capable of supporting split based operations (10 personnel each), provide emergency treatment to receive, triage, and prepare 12 incoming casualties for surgery (each) over a 72 hour period, and postoperative care for 4 patients over 6 hours post surgery. Two surgical elements, capable of supporting very short duration (24 hours) operations, consisting of only a surgical element (6 personnel) provide emergency treatment to 4 incoming casualties for surgery and limited continued postoperative care for those critically wounded/injured patients over a period of 24 hours.

34 Bleeding and airway control within 10 minutes Damage Control Resuscitation within 1 hour Aim to provide Damage Control Surgery within 1 hour but no later than 2 hours

35 What we have now What we might get What we aim for What we dream of

36 EMR/EMT/AEMT/NRP Minimum psychomotor skills EMT=NPA/OPA, PO Glucose/ASA 68W requires approx 212 hrs to AEMT 68W doing DCR!?

37 Prehospital DCR is important Lethal Triad understanding(basic yet complex) Aspects of DCR are applicable to civilian EMS(TQs, TXA, FDP, CRI/STO2)

38 USAISR CPG s PJ Medcast Dirt Medicine

39 We succeed only as we identify in life, or in war, or in anything else, a single overriding objective, and make all other considerations bend to that one objective. -GEN Dwight D. Eisenhower cord.w.cunningham.mil@mail.mil

The evolution of TQIP Best Practices for Massive Transfusion

The evolution of TQIP Best Practices for Massive Transfusion Bryan A Cotton, MD, MPH Associate Professor of Surgery Department of Surgery and The Center for Translational Injury Research University of