Amanda M. Staudt’s research while affiliated with The Geneva Foundation and other places


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Publications (45)


A trauma expert consensus: Capabilities are required early to improve survivability from traumatic injury
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July 2024

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34 Reads

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1 Citation

Journal of Trauma and Acute Care Surgery

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Russ S. Kotwal

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John B. Holcomb

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[...]

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Andrew J. Rohrer

BACKGROUND Mortality reviews examine US military fatalities resulting from traumatic injuries during combat operations. These reviews are essential to the evolution of the military trauma system to improve individual, unit, and system-level trauma care delivery and inform trauma system protocols and guidelines. This study identifies specific prehospital and hospital interventions with the potential to provide survival benefits. METHODS US Special Operations Command fatalities with battle injuries deemed potentially survivable (2001–2021) were extracted from previous mortality reviews. A military trauma review panel consisting of trauma surgeons, forensic pathologists, and prehospital and emergency medicine specialists conducted a methodical review to identify prehospital, hospital, and resuscitation interventions (e.g., laparotomy, blood transfusion) with the potential to have provided a survival benefit. RESULTS Of 388 US Special Operations Command battle-injured fatalities, 100 were deemed potentially survivable. Of these (median age, 29 years; all male), 76.0% were injured in Afghanistan, and 75% died prehospital. Gunshot wounds were in 62.0%, followed by blast injury (37%), and blunt force injury (1.0%). Most had a Maximum Abbreviated Injury Scale severity classified as 4 (severe) (55.0%) and 5 (critical) (41.0%). The panel recommended 433 interventions (prehospital, 188; hospital, 315). The most recommended prehospital intervention was blood transfusion (95%), followed by finger/tube thoracostomy (47%). The most common hospital recommendations were thoracotomy and definitive vascular repair. Whole blood transfusion was assessed for each fatality: 74% would have required ≥10 U of blood, 20% would have required 5 to 10 U, 1% would have required 1 to 4 U, and 5% would not have required blood products to impact survival. Five may have benefited from a prehospital laparotomy. CONCLUSION This study systematically identified capabilities needed to provide a survival benefit and examined interventions needed to inform trauma system efforts along the continuum of care. The determination was that blood transfusion and massive transfusion shortly after traumatic injury would impact survival the most. LEVEL OF EVIDENCE Expert Opinion; Level V.


The thin red line: Blood planning factors and the enduring need for a robust military blood system to support combat operations

July 2024

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33 Reads

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1 Citation

Journal of Trauma and Acute Care Surgery

Battlefield lessons learned are forgotten; the current name for this is the Walker Dip. Blood transfusion and the need for a Department of Defense Blood Program are lessons that have cycled through being learned during wartime, forgotten, and then relearned during the next war. The military will always need a blood program to support combat and contingency operations. Also, blood supply to the battlefield has planning factors that have been consistent over a century. In 2024, it is imperative that we codify these lessons learned. The linchpins of modern combat casualty care are optimal prehospital care, early whole blood transfusion, and forward surgical care. This current opinion comprised of authors from all three military Services, the Joint Trauma System, the Armed Services Blood Program, blood SMEs and the CCC Research Program discuss two vital necessities for a successful military trauma system: (1) the need for an Armed Services Blood Program and (2) Planning factors for current and future deployed military ere is no effective care for wounded soldiers, and by extension there is no effective military medicine.



Finding the Bleeding Edge: 24-hour Mortality by Unit of Blood Product Transfused in Combat Casualties from 2002-2020

July 2023

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41 Reads

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11 Citations

Journal of Trauma and Acute Care Surgery

Introduction: Transfusion studies in civilian trauma patients have tried to identify a general futility threshold. We hypothesized that in combat settings there is no general threshold where blood product transfusion becomes unbeneficial to survival in hemorrhaging patients. We sought to assess the relationship between the number of units of blood products transfused and 24-hour mortality in combat casualties. Methods: A retrospective analysis of the Department of Defense Trauma Registry supplemented with data from the Armed Forces Medical Examiner. Combat casualties who received at least one unit of blood product at US military medical treatment facilities (MTFs) in combat settings (2002-2020) were included. The main intervention was the total units of any blood product transfused, which was measured from the point of injury until 24 hours after admission from the first deployed MTF. The primary outcome was discharge status (alive, dead) at 24 hours from time of injury. Results: Of 11,746 patients included, the median age was 24 years, and most patients were male (94.2%) with penetrating injury (84.7%). The median injury severity score was 17 and 783 (6.7%) patients died by 24 hours. Median units of blood products transfused was 8. Most blood products transfused were red blood cells (50.2%), followed by plasma (41.1%), platelets (5.5%), and whole blood (3.2%). Among the 10 patients who received the most units of blood product (164 units to 290 units), 7 survived to 24 hours. The maximum amount of total blood products transfused to a patient who survived was 276 units. Of the 58 patients who received over 100 units of blood product, 20.7% died by 24 hours. Conclusions: While civilian trauma studies suggest the possibility of futility with ultra-massive transfusion, we report that the majority (79.3%) of combat casualties who received transfusions greater than 100 units survived to 24 hours. These results do not support a threshold for futility of blood product transfusion. Further analysis as to predictors for mortality will help in situations of blood product and resource constraints. Level of evidence: III, Prognostic/Epidemiological.



A Deeper Dive Into Combat Medic Training

February 2023

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31 Reads

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2 Citations

Military Medicine

The recent article by Knisely et al. provides a comprehensive review and summary of recent literature describing simulation techniques, training strategies, and technologies to teach medics combat casualty care skills. Some of the results reported by Knisely et al. align with the findings of our team's work, and these findings may be helpful to military leadership with their ongoing efforts to maintain medical readiness. Accordingly, we provide some additional contextual understanding to the results of Knisely et al. in this commentary. Our team recently published two papers describing the results of a large survey that examined Army medic pre-deployment training. Combining the findings of Knisely et al. along with some of the contextual information from our work, we provide some recommendations for improving and optimizing the pre-deployment training paradigm for medics.


A Retrospective Cohort Study of Burn Casualties Transported by the US Army Burn Flight Team and US Air Force Critical Care Air Transport Teams

September 2022

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27 Reads

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5 Citations

Military Medicine

Introduction The US Army Burn Center, the only burn center in the Department of Defense provides comprehensive burn care. The Burn Flight Team (BFT) provides specialized burn care during transcontinental evacuation. During Operations Iraqi and Enduring Freedom, burn injuries accounted for approximately 5% of all injuries in military personnel. To augment BFT capacity, US Air Force Critical Care Air Transport Teams (CCATTs) mobilized to transport burn patients. The purpose of this study was to describe critically ill, burn injured patients transported to the US Army Burn Center by BFT or CCATT, to compare and contrast characteristics, evacuation procedures, in-flight treatments, patient injuries/illnesses, and outcomes between the two groups. Materials and Methods We conducted a retrospective cohort study of CCATT and BFT patients, admitted to the burn ICU between January 1, 2001 and September 30, 2018. Patients with total body surface area burned (TBSA) >30% were evacuated by BFT, while CCATT evacuated patients with ≤ 30% TBSA. Results Ninety-seven patients met inclusion criteria for this study. Of these, 40 (41%) were transported by the BFT and 57 (59%) were transported by CCATTs. Compared with patients transported by CCATTs, patients transferred by the BFT had higher median TBSA and full-thickness burn size, higher prevalence of chest, back and groin burns, and higher prevalence of inhalation injury. BFT patients had increased hospital days (62 vs. 37; P = .08), ICU days (29 vs. 12; P = .003) and ventilator days (14 vs. 6; P < .001). TBSA was the only variable significantly associated with ARDS (aOR = 1.04; 95% CI: 1.01, 1.08; P = 0.04), renal failure (aOR = 1.07; 95% CI: 1.03, 1.11; P = .002), and mortality (aOR = 1.08; 95% CI: 1.03, 1.13; P = .001). Conclusions Evacuation by the BFT was associated with increased ICU and ventilator days, increased mortality, and a greater risk for developing renal failure. The severity of injury/TBSA likely accounted for most of these differences.


Task Completion Time or Percent in Novice Group and Experienced Group
Prior Extracorporeal Membrane Oxygenation (ECMO) Experience and Performance in High-Fidelity Simulation Scenarios
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  • Full-text available

September 2022

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12 Reads

Cureus

Background Extracorporeal Membrane Oxygenation (ECMO) provides a heart-lung bypass for patients with life-threatening cardiorespiratory failure. It is a classic low-volume, a high-risk procedure that requires specialized training to develop and maintain competence. Therefore, our ability to train efficiently and effectively is essential. The purpose of this study is to determine if specific participant training or experience leads to better performance in emergency ECMO scenarios during high-fidelity simulation training. Methods Fifty-one physicians, nurses, and respiratory/medical technicians participated in a study comparing an animal model vs. simulation-based ECMO education. All completed a multiple-choice questionnaire about prior ECMO experience and other demographics, as well as a four-hour pre-lab didactic session. They completed individual ECMO scenarios with both modalities during two sessions, and task completion times (minutes) and scores (percentage) were measured using a validated ECMO skills assessment tool. The scores of the 19 participants who completed the simulation-based scenarios during their first session were further analyzed in the context of their self-reported ECMO experience, and participants were divided into a novice group and an experienced group. Statistical testing included the Mann-Whitney U test (times) and Fisher’s exact test (scores). Results Data from the 19 participants who completed the simulation-based ECMO training on the first session showed no statistically significant differences in the task completion time or scores among those in the novice group vs. the experienced group in the years of ECMO experience category (28 vs. 34 minutes; p=0.66 and 61% vs. 62%; p=0.54), a number of cannulations category (30 vs. 25 minutes; p=0.11 and 59% vs. 62%; p=0.82) or the number of ECMO patients cared for category (28 vs. 34 minutes; p=0.30 and 57% vs. 62%; p=0.54). Findings were similar for both the lecture-based training and simulation-based training categories, respectively (33 vs. 28 minutes; p=0.71 and 62% vs. 60%; p=0.91 and 34 vs. 28 minutes; p=0.74 and 63% vs. 58%; p=0.12). Conclusion Among this small subset of participants, we observed no statistically significant differences in performance based on participant experience during simulation-based ECMO scenarios. The didactic/review sessions preceding the training may have contributed to an effective form of training for participants with no prior ECMO experience. Due to the small sample size of this study, further studies are needed to better elucidate what factors lead to better performance in emergency ECMO scenarios.

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Patterns of Palliation: A Review of Casualties That Received Pain Management Before Reaching Role 2 in Afghanistan

September 2022

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26 Reads

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3 Citations

Military Medicine

Introduction Battlefield pain management changed markedly during the first 20 years of the Global War on Terror. Morphine, long the mainstay of combat analgesia, diminished in favor of fentanyl and ketamine for military pain control, but the options are not hemodynamically or psychologically equivalent. Understanding patterns of prehospital analgesia may reveal further opportunities for combat casualty care improvement. Materials and Methods Using Department of Defense Trauma Registry data for the Afghanistan conflict from 2005 to 2018, we examined 2,402 records of prehospital analgesia administration to assess temporal trends in medication choice and proportions receiving analgesia, including subanalysis of a cohort screened for an indication with minimal contraindication for analgesia. We further employed frequency matching to explore the presence of disparities in analgesia by casualty affiliation. Results Proportions of documented analgesia increased throughout the study period, from 0% in 2005 to 70.6% in 2018. Afghan casualties had the highest proportion of documented analgesia (53.0%), versus U.S. military (31.9%), civilian/other (23.3%), and non-U.S. military (19.3%). Fentanyl surpassed morphine in the frequency of administration in 2012. The median age of those receiving ketamine was higher (30 years) than those receiving fentanyl (26 years) or nonsteroidal anti-inflammatory drugs (23 years). Among the frequency-matched subanalysis, the odds ratio for ketamine administration with Afghan casualties was 1.84 (95% CI, 1.30-2.61). Conclusions We observed heterogeneity of prehospital patient care across patient affiliation groups, suggesting possible opportunities for improvement toward an overall best practice system. General increase in documented prehospital pain management likely reflects efforts toward complete documentation, as well as improved options for analgesia. Current combat casualty care documentation does not include any standardized pain scale.


Characterization of Humanitarian Trauma Care by US Military Facilities During Combat Operations in Afghanistan and Iraq

July 2022

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40 Reads

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9 Citations

Annals of Surgery

Objective: To characterize humanitarian trauma care delivered by US military treatment facilities (MTFs) in Afghanistan and Iraq during combat operations. Background: International Humanitarian Law, which includes the Geneva Conventions, defines protections and standards of treatment to victims of armed conflicts. In 1949 these standards expanded to include injured civilians. In 2001, the Global War on Terror began in Afghanistan and expanded to Iraq in 2003. US MTFs provided care to all military forces, civilians, and enemy prisoners. A thorough understanding of the scope, epidemiology, resource requirements and outcomes of civilian trauma in combat zones has not been previously characterized. Methods: Retrospective cohort analysis of the Department of Defense Trauma Registry from 2005-2019. Inclusion criteria were civilians and non-NATO coalition personnel (NNCP) with traumatic injuries treated at MTFs in Afghanistan and Iraq. Patient demographics, mechanism of injury, resource requirements, procedures, and outcomes were categorized. Results: A total of 29,963 casualties were eligible from the Registry. There were 16,749 (55.9%) civilians and 13,214 (44.1%) NNCP. The majority of patients were age >13 years [26,853 (89.6%)] and male [28,000 (93.4%)]. Most injuries were battle-related: 12,740 (76.1%) civilians and 11,099 (84.0%) NNCP. Penetrating trauma was the most common cause of both battle and nonbattle injuries: 12,293 (73.4%) civilian and 10,029 (75.9%) NNCP. Median injury severity score (ISS) was 9 in each cohort with ISS scores ≥ 25 in 2,236 (13.4%) civilians and 1,398 (10.6%) NNCP. Blood products were transfused to 35% of each cohort: 5,850 civilians received a transfusion with 2,118 (12.6%) of them receiving ≥10 units; 4,590 NNCPs received a transfusion with 1,669 (12.6%) receiving ≥ 10 units. MTF mortality rates were civilians 1,263 (7.5%) and NNCP 776 (5.9%). Interventions, both operative and non-operative, were similar between both groups. Conclusions: In accordance with International Humanitarian Law, as well as the US military's medical rules of eligibility, civilians injured in combat zones were provided the same level of care as non-NATO Coalition Personnel. Injured civilians and NNCP had similar mechanisms of injury, injury patterns, transfusion needs, and ISS. This analysis demonstrates resource equipoise in trauma care delivered to civilians and NNCP. Hospitals in combat zones must be prepared to manage large numbers of civilian casualties with significant human and material resources allocated to optimize survival. The provision of humanitarian trauma care is resource-intensive, and these data can be used to inform planning factors for current or future humanitarian care in combat zones.


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Citations (25)


... To investigate the prevalence trends of neck pain among individuals aged 10-24 P r e p r i n t 3 years, we employed a multifaceted approach incorporating various statistical measures and analytical techniques [24]. To understand the trajectory of neck pain prevalence over time, we utilized estimated annual percentage changes (EAPCs), accompanied by their respective 95% confidence intervals (CIs) [25]. ...

Reference:

Temporal Trends in Neck Pain Prevalence among Adolescents and Young Adults Aged 10-24 from 1990 to 2019
Disability-Adjusted Life Years due to Ocular Injury Among Deployed Service Members, 2001-2020
  • Citing Article
  • November 2023

Ophthalmology

... Protected by copyright. 12 The investigators evaluated survival in 11 476 combat casualties who received at least one unit of blood product at US military medical treatment facilities during combat settings, between 2002 and 2020. They found that nearly 80% of combat casualties receiving greater than 100 units of blood survived to 24 hours. ...

Finding the Bleeding Edge: 24-hour Mortality by Unit of Blood Product Transfused in Combat Casualties from 2002-2020
  • Citing Article
  • July 2023

Journal of Trauma and Acute Care Surgery

... Combat medics must learn to perform life-saving medical procedures under difficult conditions, such as in active combat, austere or challenging environments, and complex multi-casualty situations (Suresh et al., 2023). To prepare for combat casualty care, simulation training is used to approximate the medical emergencies and environmental conditions medics may face in the field (Suresh et al., 2021). ...

A Deeper Dive Into Combat Medic Training
  • Citing Article
  • February 2023

Military Medicine

... 4 Compared to civilians, military burn casualties are typically more severe with higher injury scores from polytrauma, infections, and inhalation injuries. 3,[9][10][11][12][13] Despite a decrease in mortality over past decades, the optimal treatment and resuscitative regimens have yet to be developed for the burn patient. This is particularly noteworthy when burns are accompanied by hemorrhage or other trauma, [14][15][16][17] and the effect of sex on these outcomes. ...

A Retrospective Cohort Study of Burn Casualties Transported by the US Army Burn Flight Team and US Air Force Critical Care Air Transport Teams
  • Citing Article
  • September 2022

Military Medicine

... Several efforts have been directed to surgical care and maintenance of surgeon readiness in the Military Health System (MHS). The focus on surgeons and surgical teams is twofold: (1) surgeons are at risk for battlefield surgery skill degradation and (2) the integrated trauma system, which is inclusive of prehospital providers, en route care, surgical teams, and critical care specialties, is at risk for not maintaining the collective/system lessons learned. It is crucial to have ready military medical and trauma capabilities in these perilous times marked by global threats and potential risks to national and homeland security. ...

Characterization of Humanitarian Trauma Care by US Military Facilities During Combat Operations in Afghanistan and Iraq
  • Citing Article
  • July 2022

Annals of Surgery

... p = 0.001, respectively). Time from injury to TXA administration, body mass index, and total blood products transfused were also independently associated with thromboembolism (TE) [27]. ...

The risk of thromboembolic events with early intravenous 2‐ and 4‐g bolus dosing of tranexamic acid compared to placebo in patients with severe traumatic bleeding: A secondary analysis of a randomized, double‐blind, placebo‐controlled, single‐center trial
  • Citing Article
  • June 2022

Transfusion

... The RePHILL trial performed in England showed that prehospital RBC transfusion plus LyoPlas was not superior to saline resuscitation in reducing the composite outcome of episode mortality and lactate clearance in trauma bleeding patients [6]. However, the study's design and findings have been criticized, including the selection of the mortality time point in the primary outcome, the length of time elapsed from injury until the administration of the study intervention, the highly injured nature of the patients and their correspondingly high death rate [21,22]. There was, however, a 7% absolute risk reduction (25% relative risk reduction) among the PHT recipients at 3 h compared to those who were resuscitated with saline. ...

Prehospital blood transfusion for haemorrhagic shock
  • Citing Article
  • June 2022

The Lancet Haematology

... WBR was calculated for each patient by dividing the number of WB units by the sum of WB units and PRBCs units [13]. Our study patients were then categorized into four groups based on the quartiles of WBR. ...

Whole blood at the tip of the spear: A retrospective cohort analysis of warm fresh whole blood resuscitation versus component therapy in severely injured combat casualties
  • Citing Article
  • July 2021

Surgery

... In other words, as the level of psychological empowerment increases, so does the strength of nurses' intent to stay. Nurses working in military hospitals bear unique responsibilities and tasks that differ from those associated with nurses working in local hospitals, such as supporting military missions and caring for war injuries (Suresh et al. 2021). The accumulation of these duties and tasks can cause psychological changes in nurses, thus leading them to adopt negative attitudes towards their responsibilities and missions; in turn, these attitudes reduce their job autonomy and intent to stay (House et al. 2022). ...

Pre-deployment training of Army medics assigned to prehospital settings
  • Citing Article
  • May 2021

Journal of Trauma and Acute Care Surgery

... The purpose of this study was to assess mortality, key risk factors for secondary amputation, and early care results in patients with penetrating femoropopliteal vascular injuries during a period of conflict. The fasciotomy procedure was liberally and successfully used in more than half of our patients (n = 33, 51%), aligning with the rates reported in other studies [3,25]. It was indicated for accurate muscle assessment in 46.2%, prolonged ischemia > 6 h in 31%, compartment syndrome at presentation in 28%, combined arterial and venous injuries in 18.5%, and prophylactically in 15%. ...

Early Fasciotomy and Limb Salvage and Complications in Military Lower Extremity Vascular Injury
  • Citing Article
  • November 2020

Journal of Surgical Research