Death on the battlefield (2001-2011): Implications for the future of combat casualty care

From the US Army Institute of Surgical Research (B.J.E., R.L.M., T.E.R., L.H.B.), Fort Sam Houston, Texas
The journal of trauma and acute care surgery 12/2012; 73(6 Suppl 5):S431-7. DOI: 10.1097/TA.0b013e3182755dcc
Source: PubMed


Critical evaluation of all aspects of combat casualty care, including mortality, with a special focus on the incidence and causes of potentially preventable deaths among US combat fatalities, is central to identifying gaps in knowledge, training, equipment, and execution of battlefield trauma care. The impetus to produce this analysis was to develop a comprehensive perspective of battlefield death, concentrating on deaths that occurred in the pre-medical treatment facility (pre-MTF) environment.
The Armed Forces Medical Examiner Service Mortality Surveillance Division was used to identify Operation Iraqi Freedom and Operation Enduring Freedom combat casualties from October 2001 to June 2011 who died from injury in the deployed environment. The autopsy records, perimortem records, photographs on file, and Mortality Trauma Registry of the Armed Forces Medical Examiner Service were used to compile mechanism of injury, cause of injury, medical intervention performed, Abbreviated Injury Scale (AIS) score, and Injury Severity Score (ISS) on all lethal injuries. All data were used by the expert panel for the conduct of the potential for injury survivability assessment of this study.
For the study interval between October 2001 and June 2011, 4,596 battlefield fatalities were reviewed and analyzed. The stratification of mortality demonstrated that 87.3% of all injury mortality occurred in the pre-MTF environment. Of the pre-MTF deaths, 75.7% (n = 3,040) were classified as nonsurvivable, and 24.3% (n = 976) were deemed potentially survivable (PS). The injury/physiologic focus of PS acute mortality was largely associated with hemorrhage (90.9%). The site of lethal hemorrhage was truncal (67.3%), followed by junctional (19.2%) and peripheral-extremity (13.5%) hemorrhage.
Most battlefield casualties died of their injuries before ever reaching a surgeon. As most pre-MTF deaths are nonsurvivable, mitigation strategies to impact outcomes in this population need to be directed toward injury prevention. To significantly impact the outcome of combat casualties with PS injury, strategies must be developed to mitigate hemorrhage and optimize airway management or reduce the time interval between the battlefield point of injury and surgical intervention.Understanding battlefield mortality is a vital component of the military trauma system. Emphasis on this analysis should be placed on trauma system optimization, evidence-based improvements in Tactical Combat Casualty Care guidelines, data-driven research, and development to remediate gaps in care and relevant training and equipment enhancements that will increase the survivability of the fighting force.

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Available from: Charles Wade, Mar 02, 2015
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    • "All (195) identified participants received an online questionnaire in the last quarter of 2013 (mean $3 years after deployment), two digital reminders and in case of no response a reminder by telephone. The first part of the questionnaire (Supplemental data 2) was based on current literature [2] [4] [5] [10] [13], and screened for validity and relevance by an expert board of Dutch military medical specialists (Delphi method). It focused on three main topics: (1) participants general background, (2) exposure to combat (casualty) situations, and (3) self-perceived QoC in the pre-hospital phase (QoC was described as the subjective judgment by the participants, and expressed in a numeric variable from 1 [low] to 10 [high]; in this study we defined a score of 7 as average). "
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    Injury 12/2014; 155(5). DOI:10.1016/j.injury.2014.12.012 · 2.14 Impact Factor
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    • "Civilian data estimates between 1400 and 14,000 preventable hemorrhagic trauma deaths occur per year in the United States [2]. Military data has consistently reported hemorrhagic shock as the leading cause of preventable deaths [3]–[5]. "
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    PLoS ONE 06/2014; 9(6):e100088. DOI:10.1371/journal.pone.0100088 · 3.23 Impact Factor
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    • "3,4 , 6–8 In the prehospital period, hemorrhage contributes to 33–56% of civilian trauma-related deaths and in recent military operations uncontrolled hemorrhage was the primary cause of potentially survivable battlefield death. 3 , 8–13 Due to the critical need for early and effective control of hemorrhage, significant research has been invested in new technologies to control hemorrhage, such as the development of hemostatic agents and use of tranexamic acid (TXA). "
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