While early plasma transfusion for the treatment of patients with ongoing major hemorrhage is widely accepted as part of the standard of care in the hospital setting, logistic constraints have limited its use in the out-of-hospital setting. Freeze-dried plasma (FDP), which can be stored at ambient temperatures, enables early treatment in the out-of-hospital setting. Point-of-injury plasma transfusion entails several significant advantages over currently used resuscitation fluids, including the avoidance of dilutional coagulopathy, by minimizing the need for crystalloid infusion, beneficial effects on endothelial function, physiological pH level, and better maintenance of intravascular volume compared with crystalloid-based solutions. The Israel Defense Forces Medical Corps policy is that plasma is the resuscitation fluid of choice for selected, severely wounded patients and has thus included FDP as part of its armamentarium for use at the point of injury by advanced life savers, across the entire military. We describe the clinical rationale behind the use of FDP at the point-of-injury, the drafting of the administration protocol now being used by Israel Defense Forces advanced life support providers, the process of procurement and distribution, and preliminary data describing the first casualties treated with FDP at the point of injury. It is our hope that others will be able to learn from our experience, thus improving trauma casualty care around the world.

Currently available triage and monitoring tools are often late to detect life-threatening clinically significant physiological aberrations and provide limited data in prioritizing bleeding patients for treatment and evacuation. The Compensatory Reserve Index (CRI) is a novel means of assessing physiologic reserve, shown to correlate with central blood volume loss under laboratory conditions. The purpose of this study was to compare the noninvasive CRI device with currently available vital signs in detecting blood loss. Study subjects were soldiers volunteering for blood donation (n = 230), and the control group was composed of soldiers who did not donate blood (n = 34). Data collected before and after blood donation were compared, receiver operator characteristic curves were generated after either donation or the appropriate time interval, and areas under the curves (AUCs) were compared. Compared with pre-blood loss, blood donation resulted in a mean reduction of systolic blood pressure by 3% (before, 123 mmHg; after, 119 mmHg; P < 0.01). The CRI demonstrated a 16% reduction (before, 0.74; after, 0.62; P < 0.01). Heart rate, diastolic blood pressure, and oxygen saturation remained unchanged. The AUC for change in CRI was 0.81, 0.56 for change in heart rate, 0.53 for change in systolic blood pressure, 0.55 and 0.58 for pulse pressure and shock index, respectively. The AUCs for detecting mild blood loss at a single measurement were 0.73 for heart rate, 0.60 for systolic blood pressure, 0.62 for diastolic blood pressure, 0.45 for pulse oximetry, and 0.84 for CRI. The CRI was better than standard indices in detecting mild blood loss. Single measurement of CRI may enable a more accurate triage, and CRI monitoring may allow for earlier detection of casualty deterioration.

Therapeutic study, level V.

BACKGROUND The Israeli Defense Force Medical Corps (IDF-MC) is routinely collecting prehospital data to establish a prehospital registry. Since February 2013, Israel has been providing medical care to Syrian refugees. This unique humanitarian aid begins in prehospital settings and typically culminates in Israeli civilian hospitals. This report describes the accumulated experience of the IDF-MC to provide Syrian refugees with prehospital treatment. METHODS Care provided by IDF-MC medical teams, including prehospital casualty care, is regularly documented and after-action reports are conducted. Records of casualties arriving at the Israeli-Syrian border from February 16, 2013, to December 31, 2017, were prospectively extracted from the IDF Trauma Registry. Patients who did not have a casualty card were excluded. The database included demographic information, injury signature and treatment given. RESULTS During the study period, 2,785 Syrian casualties were treated, of whom 2,339 were trauma victims. The most common mechanism of injury was penetrating (60.4%). Prehospital lifesaving interventions included 127 endotracheal intubations, 30 cricothyroidotomies, 55 chest decompressions, and 58 tourniquets for extremity hemorrhage control. Remote Damage Control Resuscitation included reconstituted freeze-dried plasma (n = 75) and tranexamic acid (n = 222 casualties) with no adverse effects. CONCLUSION The experience of the IDF-MC teams in caring for civilian casualties along a hostile international border is unique. In this capacity, the IDF-MC has demonstrated effectiveness in providing lifesaving and resuscitative interventions including tranexamic acid and freeze-dried plasma. In this experience, tourniquets have been effective in controlling hemorrhage when applied early and endotracheal intubation and cricothyroidotomy have provided effective airway options in select patients. Prehospital combat casualty care presents a significant challenge both in terms of providing adequate care and in terms of data collection and analysis. The experience described in this article is one example of effective, ongoing prehospital data gathering process. Efforts to provide medical relief to victims of the Syrian civil war continue to this day. While we hope for a better future, as long as these lessons continue to accumulate, it is our obligation to use them to support improvement of trauma care and hopefully save more lives. LEVEL OF EVIDENCE Therapeutic, level III.