» Used penicillins
• Somalia
– Pseudomonas and polymicrobial
• Russian Afghanistan Experience
– Clostridial
» Recommended PCN, Rifampin, Metronidazole, or Ceftriaxone
review • 32 comparing outcome, 7 comparing
pharmacokinetics & cost.
The EAST Practice Management Guidelines (cont)
• Looking mostly at Class 1 articles:
– More successful regiments included :
• cefoxin • clindamycin with gentamycin • tobramycin with clindamycin • cefotetan • cefamandole • aztreonam • gentamycin
• Early Immobilizatio
n of Fractures
– Soft tissue damage
Antibiotics
• Finite period of time in which infection can be prevented.
– Miles, Burke.
• How early, not how long.
• Waterborne Ops
– Sea Water – Vibrio
• Overwhelming Gm Neg sepsis – 50% mortality
– Fresh Water - Aeromonas
Our Environment
Our Environment
Tactical Field Care “What We Want in an Antibiotic”
Korea
• Scott, 1954:
–“In any tactical situation where the casualty cannot reach the aid station until 4-5 hours or longer after wounding, antibiotic therapy by the aidman in the field is most desirable”
• bridement
– excise devitalized tissue
• Irrigation
– high pressure, solution
• Eliminate Dead Space
– fluid, blood
• Delayed Primary Closure (DPC)
– 4 - 6 days
Examples
of Operational Need Stimulating Scientific
Innovation
Antibiotics and Pain Control
WW II
• Poole, 1944:
–“The greatest lesson learned from World War II may have been the benefit of the use of penicillin prophylactically in the surgical units close to the front.”
• A,B,C’s
• * Need to maintain a “nearly normal” arterial oxygen tension.
• Volume Expansion Considerations
Early Wound Care
• Sterile Dressing
– contamination, desiccation
– Fullen, et al.
• Both the timing and the choice are important.
– Thadepalli, et al.
What Bugs?
• Yom Kippur War
– Pseudomonas – 25.6% isolates – Gm Neg bacilli – 70% isolates overall
The EAST Practice Management Guidelines
• The Journal of Trauma - March 2000 • Meta-analysis - MEDLINE Search for
1976-1997 • After discrimination - 39 articles for
Why not?!
• Antibiotics not routinely given in the field by civilian pre-hospital personnel (EMT/paramedic model for
medic training).
• Combat medics don’t typically see wound infections during the time they care for them – may not appreciate their devastating effect.
General Preventive Measures
• Adequate and Timely Resuscitation
• Early Wound Care • Antibiotics • Tetanus Immune Prophylaxis
Adequate and Timely Resuscitation
• Not a “sexy” topic. • Ivory Tower arrogance….
Increased Risk of Infection in Trauma Patients
• Disruption of Mechanical Barriers
• Bacterial Contamination • Local Wound Factors • Invasive Interventions • Impaired Resistance