• Featured News

  • US Military Adopts Checklist for Trauma and Emergency Anesthesia



    A checklist for trauma and emergency anesthesia, published last year inAnesthesia & Analgesia, has been included in the US Department of Defense's Joint Theater Trauma System Clinical Practice Guideline for trauma anesthesia.

    Developed by a group of experts from anesthesiology departments across the United States, the checklist originally appeared in the November, 2013, issue ofAnesthesia & Analgesia. The lead author was Dr Joshua M. Tobin of David Geffen School of Medicine at UCLA. The checklist was integrated into the newly developed Joint Theater Trauma System Clinical Practice Guideline for Trauma Anesthesia (PDF link), approved in June, 2014.

    Checklist to Guide Trauma Anesthesia Care in US Military Settings

    As part of the new Joint Theater Trauma System guideline, the checklist will help to guide emergency and trauma anesthesia across US military medical settings, including care for combat injuries. It provides a quick reference to essential steps at each phase of trauma anesthesia—from the time the operating room is notified to expect casualties, to the patient's emergence from anesthesia.

    A technique borrowed from aviation, standardized checklists are increasingly used to guide several aspects of complex medical care. Having a checklist can be especially useful in emergency settings. "The checklist assures that critical steps are not missed," Dr Tobin and coauthors write. "Checklists are easy. Missing critical steps can be deadly."

    The newly developed clinical practice guideline outlines an approach incorporating the induction and maintenance of anesthesia into ongoing resuscitation during surgery for personnel with severe trauma. It guides all members of the military trauma surgical team through the five steps of the trauma anesthesia process: pre-induction, induction, and maintenance of anesthesia, resuscitation, and postoperative care.

    The guideline also includes steps for performance improvement monitoring, to ensure that expected outcomes of trauma anesthesia care are being met and that the performance/adherence measures are being followed. It was approved after an extensive review process involving the anesthesiology specialty leaders of the Army, Navy, and Air Force, as well as trauma advisors of the respective branches.

    "We congratulate our authors on having their trauma anesthesia checklist incorporated into this important new military clinical practice guideline," comments Dr. Steven L. Shafer of Stanford University, Editor-in-Chief of Anesthesia & Analgesia. "This is an outstanding example of the evidence-based quality improvement processes that have led to the tremendous recent advances in surgical care and resuscitation of combat casualties."

    Read the article in Anesthesia & Analgesia.
    Comments 6 Comments
    1. Johnga's Avatar
      Johnga -
      This came out a couple of weeks before I got to Afghanistan. It doesn't take into account that we resuscitate patients on arrival in the EMT (emergency medical treatment) section as well. We generally follow an assessment and treatment pathway like in ATLS w/modifications depending on how long the patient was bleeding on the battlefield and what class of shock they are in on arrival. This seems like it is more designed for someone that would go straight into OR without the preop/ATLS interventions which is not common. Many of these clinical practice guidelines or CPGs are designed for Role III facilities and overlook Role IIs. Role IIIs have platelets, we do not and cannot provide 1:1:1 therapy. Additionally, FFP takes 25-35 minutes to thaw which is a very long time for some of our wounded so they often don't get 1:1 FFP/PRBC replacement initially although it may equal out among what is given in EMT, OR, and ICU.
      Most studies don't indicate if the patients received these ratios together, or if it was later averaged. They also don't differentiate how many units of what product were given before operative repair started.
      If I can see from the vitals during evacuation that the patient is in Class III or IV shock, the FMS 2000 is already primed with 2units of PRBCs and the minute they hit the bed they are getting large-bore IV access and blood while I'm assessing the airway, chest, face, skull, and neck. I can thaw Cryo in 3 minutes vs. the avg of 30 for FFP, providing clotting factors as well as THAM and TXA. By the time the patient goes to OR some of what is described in this CPG is already done.
      As it says in the CPG "Guideline only-not a substitute for clinical judgement".
    1. J-Dubya's Avatar
      J-Dubya -
      Quote Originally Posted by Johnga View Post
      This came out a couple of weeks before I got to Afghanistan. It doesn't take into account that we resuscitate patients on arrival in the EMT (emergency medical treatment) section as well. We generally follow an assessment and treatment pathway like in ATLS w/modifications depending on how long the patient was bleeding on the battlefield and what class of shock they are in on arrival. This seems like it is more designed for someone that would go straight into OR without the preop/ATLS interventions which is not common. Many of these clinical practice guidelines or CPGs are designed for Role III facilities and overlook Role IIs. Role IIIs have platelets, we do not and cannot provide 1:1:1 therapy. Additionally, FFP takes 25-35 minutes to thaw which is a very long time for some of our wounded so they often don't get 1:1 FFP/PRBC replacement initially although it may equal out among what is given in EMT, OR, and ICU.
      Most studies don't indicate if the patients received these ratios together, or if it was later averaged. They also don't differentiate how many units of what product were given before operative repair started.
      If I can see from the vitals during evacuation that the patient is in Class III or IV shock, the FMS 2000 is already primed with 2units of PRBCs and the minute they hit the bed they are getting large-bore IV access and blood while I'm assessing the airway, chest, face, skull, and neck. I can thaw Cryo in 3 minutes vs. the avg of 30 for FFP, providing clotting factors as well as THAM and TXA. By the time the patient goes to OR some of what is described in this CPG is already done.
      As it says in the CPG "Guideline only-not a substitute for clinical judgement".
      That's a shame you guys don't a rapid thawer over there for the FFP.
    1. FST6's Avatar
      FST6 -
      I remember thawing FFP using hot water in the bathroom sinks (we didn't have a plasma thawer quite yet). Strangely, that practice was not mentioned in the new guidelines. Ah, the joys of a Role II in Afcrapistan.
    1. Johnga's Avatar
      Johnga -
      I'm jealous you had a bathroom! We had portable toilets.
    1. armygas's Avatar
      armygas -
      We sat in a wooden box with a hole cut out and shitted in a half of a barrel.....
    1. ckh23's Avatar
      ckh23 -
      We had wag bags in Iraq. They made the FOB smell awesome when hundreds of them went to the burn pit.