Vandehoef - Lessons learned at 20

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					          Lessons learned at 20,000 feet over Southern Afghanistan
                     LtCol Scott Vandehoef,USAF, MC, FS, FAAFP
        Using recent cases from both Afghanistan and Iraq (with lots of cool pictures),
the following key concepts will be reinforced. Today's military Family Physician often
finds themselves on the front lines in the ongoing "War on Terror" as well as the being
asked to care for CONUS sick, burnt, and trauma patients. The goal of this lecture will
be to assist Family Physicians in staying abreast of recent changes in shock, patient
stabilization, and burn management.
Redefining shock:
       Classic medical school teaching of low blood pressure, high heart rate, low urine
output and change in mental status does not pick up compensated shock, misses
underlying coagulopathy, and often leads to a false sense of comfort. Previously
healthy trauma patients often maintain normal vitals despite having significant tissue
hypoxia, coagulopathy, and blood loss.
       Newer definitions utilize a base deficit > 6 allowing the rapid detection of tissue
hypoxia. The "bloody vicious cycle of trauma" requires immediate recognition and
correction and is more quickly identified looking for an INR >1.5, temp <36, and initial
Hgb of <11. Lastly, an initial SBP of <90 is associated with a increase in mortality.
Redefining shock during Triage:
       Triage needs to be quick, reproducible, and capable of being done in noisy,
chaotic environment without the benefit of labs, stethoscopes, BP cuffs, or having to
remember GCS scoring. Civilian triage has demonstrated a greater than 50% over
triage causing the waste of costly and limited supplies
        Point of Injury responders and Triage officers (often a FP doc) increasingly are
using the Tactical Combat Casualty Care method. Walking and talking patients are
quickly sorted into minimal status. Obviously fatal injuries equally rapid into expectant.
The ability to follow commands and a radial pulse are then used to triage the remainder
into either immediate or delayed using a very easy to remember algorithm. Appendix 1
Correction of shock/What is a stabilized patient:
       CCATT has greatly extended ICU abilities to the most remote Forward Operating
Base with a runway and now Tac-Evac initiatives are utilizing similar technology on
rotary wing platforms. Proper patient prep and "stabilizing" a patient requires
knowledge of new shock paradigms and how best to correct them acutely....
1) Hemostatic Resuscitation: Rely on your surgeons to stop the bleeding but recognize
that in the ED's and ICU's down range you will often times be in charge of resuscitation.
This is a rapid evolving field that has come full circle over the past 40 years and is
headed back to warm, fresh, whole blood resuscitation. Currently this translates into
minimal isotonic saline, immediate use of PRBC and FFP in a 1:1 ratio, liberal use of
platelets and cryoprecipitate, and increasingly Factor VII. Appendix 2
2) Preventing coagulopathy: early recognition utilizing INRs, early use of FFP and
Cryoprecipitate, and near religious fervor in keeping patients warm are the cornerstone
to treatment as it is significantly easier to prevent than interrupt once started. There is a
reason that the trauma bay at Bagram is called the "hot box". Having and knowing how
to use Rescue Blankets, "Ready Heat" Blankets", Fluid warmers, Thermal Angels,
"Popcorn Hats" and Bair Huggers are fundamental to good outcomes in Afghanistan
during the winter and CCATT anytime of the year.
Maximizing patient Hand-Offs :
       70% of Joint Commission sentinel events in the last 10 years occurred as a result
of a "communication breakdown during hand-offs". Downrange a patient may transit
through as many as 7-8 care teams over 24 hours and 6000 miles making the problem
of hand-offs that much greater. Developing a method of patient hand-off consistency
like "SBAR" can be the difference between life and death as well as avoids redundant
surgeries, critical medication dosing mistakes, and wasted resources. "SBAR" is one
method now being taught in FP residencies that has a vital "down-range" impact. The
CCATT 3899 tries to capture this data during AE. Appendix 3
Parkland was good, but not good enough:
        Recent re-evaluation of burn care in the AOR found that patients were frequently
fluid overloaded. This lead to worsening airway status, increased inflammatory
changes, increased need for escharatomy, and increased morbidity and mortality. Poor
record keeping and the lack of well documented hourly flow sheets only served to
worsen this problem.
        The new CPG now starts with 1-2ml/kg/%BSA of LR as an initial guideline for 24
hour predicted resuscitation. In addition, no fluid boluses are given, hourly changes in
fluid rate based on a goal MAP of >55 and UOP of 30ml/hr, and the increasingly routine
use of Vasopressin at a dose of .02 units per minute are considered the new standard
of care. Lastly, the INITIAL provider taking care of any partial or full thickness burn
>20% total body surface area should be initiating the JTTS Burn Resuscitation Flow
Sheet once again driving home the point of good patient hand-off. Appendix 4

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