Casualty Lessons Learned, Trends, and Statistics

#### COMBAT CASUALTY CARE LESSONS LEARNED, CASE REPORTS, CASUALTY TRENDS & STATISTICS

J Trauma Acute Care Surg. 2019 Jul;87(1S Suppl 1):S165-S171

# Prehospital Trauma Experience of the Israel Defense Forces on the Syrian Border 2013-2017.

Benov A, Shkolnik I, Glassberg E, Nadler R, Gendler S, Antebi B, Chen J, Fink N, Bader T

BACKGROUND: The Israeli Defense Force Medical Corps (IDF-MC) is routinely collecting pre-hospital data to establish a pre-hospital registry. Since February 2013, Israel has been providing medical care to Syrian refugees. This unique humanitarian aid begins in pre-hospital 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 pre-hospital casualty care, is regularly documented and after-action reports are conducted. Records of casualties arriving at the Israeli-Syrian border from February 16th, 2013 to December 31th 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, 2785 Syrian casualties were treated, of whom 2339 were trauma victims. The most common mechanism of injury was penetrating (60.4%). Pre-hospital life-saving 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 (FDP; n=75) and transexamic acid (TXA; n=222 casualties) with no adverse effects.

CONCLUSIONS: 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 life-saving and resuscitative interventions including TXA and FDP. 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 paper is one example of effective, ongoing pre-hospital 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: Study type - therapeutic III.

JAMA Surg. 2019 Feb 6. Epub ahead of print

# Association Between Emergency Medical Service Response Time and Motor Vehicle Crash Mortality in the United States.

Byrne J, Mann N, Dai M, Mason S, Karanicolas P, Rizoli S, Nathens A

Importance: Motor vehicle crashes (MVCs) are a leading public health concern. Emergency medical service (EMS) response time is a modifiable, system-level factor with the potential to influence trauma patient survival. The relationship between EMS response time and MVC mortality is unknown.

Objectives: To measure the association between EMS response times and MVC mortality at the population level across US counties.

Design, Setting, and Study Population: This population-based study included MVC-related deaths in 2268 US counties, representing an estimated population of 239 464 121 people, from January 1, 2013, through December 31, 2015. Data were analyzed from October 1, 2017, through April 30, 2018.

Exposure: The median EMS response time to MVCs within each county (county response time), derived from data collected by the National Emergency Medical Service Information System. Main Outcomes and Measures: The county rate of MVC-related death, calculated using crash fatality data recorded in the Fatality Analysis Reporting System of the National Highway Traffic Safety Administration.

Results: During the study period, 2 214 480 ambulance responses to MVCs were identified (median, 229 responses per county [interquartile range (IQR), 73-697 responses per county]) in 2268 US counties. The median county response time was 9 minutes (IQR, 7-11) minutes. Longer response times were significantly associated with higher rates of MVC mortality (≥12 vs <7 minutes; mortality rate ratio, 1.46; 95% CI, 1.32-1.61) after adjusting for measures of rurality, on-scene and transport times, access to trauma resources, and traffic safety laws. This finding was consistent in both rural/wilderness and urban/suburban settings, where a significant proportion of MVC fatalities (population attributable fraction: rural/wilderness, 9.9%; urban/suburban, 14.1%) were associated with prolonged response times (defined by the median value, ≥10 minutes and ≥7 minutes, respectively).

Conclusions and Relevance: Among 2268 US counties, longer EMS response times were associated with higher rates of MVC mortality. A significant proportion of MVC-related deaths were associated with prolonged response times in both rural/wilderness and urban/suburban settings. These findings suggest that trauma system-level efforts to address regional disparities in MVC mortality should evaluate EMS response times as a potential contributor.

Injury. 2019 Jan;50(1):46-53

# Massive hemorrhage protocol survey: Marked variability and absent in one-third of hospitals in Ontario, Canada.

Chin V, Cope S, Yeh C, Thompson T, Nascimento B, Pavenski K, Callum J; QUEST Research Group.

BACKGROUND: Massive hemorrhage protocols (MHP) are critical to standardized delivery of timely, safe, and resource-effective coordinated care for patients with life-threatening bleeding.

METHODS: A standardized MHP survey was sent to all hospitals (n = 150) in Ontario with a transfusion service. This study aim was to determine the proportion of hospitals with an MHP and assess for ariability.

RESULTS: The overall survey completion rate was 133 of 150 hospitals (89%) (remaining 17 providing negative affirmation that they did not have an MHP). A MHP was in place at 97 of 150 (65%) hospitals (60% of small (<5000 red cell units/year) vs. 91% of medium/large). A total of 10 different names of protocols were reported, with "Massive Transfusion Protocol" (68%) predominating. Activation criteria were present in 82 of 97 (85%); commonly activated based on volume of blood loss (70%). Blood work was drawn at the discretion of the physician (37%) or at predefined intervals (31%; majority every 60 min). Common routine laboratory tests performed were CBC (87%) and INR (84%). Fibrinogen testing was available at 88 (66%) of 133 reporting hospitals and part of the standard testing at 73 of 97 (75%) hospitals with an MHP. Median targets of hemostatic resuscitations, stated in the protocol at 49% of hospitals with an MHP, were: platelets >50 × 109/L, INR < 1.8, fibrinogen >1.5 g/L, and hemoglobin >70 g/L. Protocol required patient temperature monitoring in 65% and specified a reversal plan for patients on anticoagulants in 59%. At 36% of sites all patients are initially managed with O RhD negative blood. Overall, 61% of sites issue blood in predefined packs (vs. on demand). Hemostatic agents in protocols included: tranexamic acid (70%), prothombin complex concentrate (14%), fibrinogen concentrate (13%), and recombinant FVIIa (4%). Quality metrics were tracked in 32% of hospitals.

CONCLUSIONS: A third of hospitals lack formal MHPs, with the majority lacking in smaller hospitals. The survey results indicate that there is marked variability in all key aspects of the reported MHPs. This may be due to differences in hospital resources and personnel, lack of supporting evidence to dictate requirements, and differences in knowledge base of the individuals involved in protocol setting.

J Spec Oper Med. Winter 2018;18:82-86.

# Willingness of Emergency Medical Services Professionals to Respond to an Active Shooter Incident.

Chovaz M, Patel RV, March JA, Taylor SE, Brewer KL.

BACKGROUND: Historically, staging of civilian emergency medical services (EMS) during an active shooter incident was in the cold zone while these professionals awaited the scene to be completely secured by multiple waves of law enforcement. This delay in EMS response has led to the development of a more effective method: the Rescue Task Force (RTF). The RTF concept has the second wave of law enforcement escorting civilian EMS into the warm zone, thus decreasing EMS response time. To our knowledge, there are no data regarding the willingness of EMS professionals to enter a warm zone as part of an RTF. In this study, we assessed the willingness of EMS providers to respond to an active shooter incident as part of an RTF.

METHODS: A survey was distributed at an annual, educational EMS conference in North Carolina. The surveys were distributed on the first day of the conference at the beginning of a general session that focused on EMS stress and wellness. Total attendance was measured using identification badges and scanners on exiting the session. Data were assessed using χ2 analysis, as were associations between demographics of interest and willingness to respond under certain conditions. A p value < .01 indicated statistical significance.

RESULTS: The overall response rate was 76% (n = 391 of 515 session attendees). Most surveys were completed by paramedics (74%; n = 288 of 391). Most EMS professionals (75%; n = 293 of 391) stated they would respond to the given active shooter scenario as part of an RTF (escorted by the second wave of law enforcement) if they were given only ballistic gear. However, most EMS professionals (61%; n = 239 of 391) stated they would not respond if they were provided no ballistic gear and no firearm. Those with tactical or military training were more willing to respond with no ballistic gear and no firearm (49.6%; n = 68 of 137) versus those without such training (31%; n = 79 of 250; odds ratio, 2.2; 95% confidence interval, 1.4-3.3; p < .001).

CONCLUSION: EMS professionals are willing to put themselves in harm's way by entering a warm zone if they are simply provided the proper training and ballistic equipment.

Anesthesiol Clin. 2019 Mar;37(1):183-193

# Future Trends in Trauma Care: Through the Lens of the Wounded How Lessons from the Battlefield May Be Used at Home.

D'Angelo M, Welder M, Chauhan R, Kearns M

The coordinated terrorist attacks of 2001 thrust the United States and its allies to war. Through an evolving battlefield, the paradigm of large fixed medical facilities advanced to become nimble surgical and resuscitative platforms, able to provide care far forward. Innovations like tactical combat casualty care, evacuation, fresh whole-blood administration, freeze-dried plasma, and forward surgical care military medicine helped reduce combat mortality to its lowest levels in history. Through the account of a young wounded marine wounded in Iraq, this article examines how innovations on the battlefield saved casualties and explores how these techniques may be applied at home.

Ann Surg. 2018 Jul 31 Epub ahead of print

# Establishing a Regional Trauma Preventable/Potentially Preventable Death Rate.

Drake S, Holcomb J, Yang Y, Thetford C, Myers L, Brock M, Wolf D, Cron S, Persse D, McCarthy J, Kao L, Todd S, Naik-Mathuria B, Cox C, Kitagawa R, Sandberg G, Wade C

OBJECTIVE: To establish a trauma preventable/potentially preventable death rate (PPPDR) within a heavily populated county in Texas.

SUMMARY: The National Academies of Sciences estimated the trauma preventable death rate in the United States to be 20%, issued a call for zero preventable deaths, while acknowledging that an accurate preventable death rate was lacking. In this absence, effective strategies to improve quality of care across trauma systems will remain difficult.

METHODS: A retrospective review of death-related records that occurred during 2014 in Harris County, TX, a diverse population of 4.4 million. Patient demographics, mechanism of injury, cause, timing, and location of deaths were assessed. Deaths were categorized using uniform criteria and recorded as preventable, potentially preventable or nonpreventable.

RESULTS: Of 1848 deaths, 85% had an autopsy and 99.7% were assigned a level of preventability, resulting in a trauma PPPDR of 36.2%. Sex, age, and race/ethnicity varied across preventability categories (P < 0.01). Of 847 prehospital deaths, 758 (89.5%) were nonpreventable. Among 89 prehospital preventable/potentially preventable (P/PP) deaths, hemorrhage accounted for 55.1%. Of the 657 initial acute care setting deaths, 292 (44.4%) were P/PP; of these, hemorrhage, sepsis, and traumatic brain injury accounted for 73.3%. Of 339 deaths occurring after initial hospitalization, 287 (84.7%) were P/PP, of these 117 resulted from sepsis and 31 from pulmonary thromboembolism, accounted for 51.6%.

CONCLUSIONS: The trauma PPPDR was almost double that estimated by the National Academies of Sciences. Data regarding P/PP deaths offers opportunity to target research, prevention, intervention, and treatment corresponding to all phases of the trauma system.

Mil Med. 2018 Nov 1;183(11-12):e758-e761

# Isolated Common Femoral Artery Injury Resulting from Blunt Military Trauma.

Park H, Kim K

The incidence of an isolated femoral vessel injury in the absence of fractures or other organ injury is extremely rare. A 20-yr-old male Korean soldier was taken to the hospital with a common femoral artery (CFA) obstruction. Injured CFA segment was resected and replaced by using 7-mm PTFE (polytetrafluoroethylene) graft. Two months after the surgical treatment, the patient discharged from the hospital without any complaints or postoperative complications. We report an unusual case of isolated femoral artery injury due to blunt trauma during military service with following review of literature.

Mil Med. 2018 Nov 5;Epub ahead of print

# The First 30 Months Experience in the Non-Doctrinal Operation Inherent Resolve Medical Theater.

Schauer S, Naylor J, April M, Thronson E, Maddry J, Becker T, Gross K

Introduction: U.S. military forces were redeployed in 2014 in support of Operation Inherent Resolve (OIR), operating in an austere theater without the benefit of an established medical system. We seek to describe the prehospital and hospital-based care delivered in this medically immature, non-doctrinal theater.

Materials and Methods: We queried the Department of Defense Trauma Registry (DODTR) for all encounters associated with OIR from August 2014 through June 2017. We sought all available prehospital and hospital-based data.

Results: There were a total of 826 adults that met inclusion; 816 were from Iraq and the remaining 10 were from Syria. The median age was 21 years and the most frequent mechanism of injury was explosives (47.7%). Median composite injury severity scores were low (9, IQR 2.75-14) and the most frequent seriously injured body region was the extremities (23.0%). Most subjects (94.9%) survived to hospital discharge. Open fractures were the most frequent major injury (26.0%). In the prehospital setting, opioids were the most frequently administered medication (9.3%) and warming blanket application (48.7%) and intravenous line placement (24.8%) were the most frequent interventions. In the emergency department, Focused Assessment with Sonography in Trauma exams (64.3%) was the most frequently performed study and endotracheal intubations were the most frequent (29.9%) procedure. In the operating room, the most frequently performed procedure was exploratory laparotomy (12.3%).

Conclusions: Host nation military males injured by explosion comprised the majority of casualties. Open fracture was the most common major injury. Hence, future research should focus upon the unique challenges of delivering care to members of partner forces with particular focus upon interventions to optimize outcomes among patients sustaining open fractures.

Prehosp Emerg Care. 2018 Dec 27:1-8.

# Analysis of Injuries and Prehospital Interventions Sustained by Females in the Iraq and Afghanistan Combat Zones.

Schauer S, Naylor J, Long A, Mora A, Le T, Maddry J, April M

BACKGROUND: Women served in both combat and non-combat units in the recent conflicts in Iraq and Afghanistan. Moreover, the recent conflicts lacked traditional separation of civilians from combatants carrying additional risk for injury to local civilians. There is a relative paucity of data specific to this topic. We compare injury patterns and interventions performed in the prehospital, combat setting among females versus males.

METHODS: This is a secondary analysis of previously published data from the Department of Defense Trauma Registry. We included all subjects that had at least one prehospital intervention documented. We compared variables between females and males.

RESULTS: From January 2007 to August 2016, our inclusion criteria captured 19,485 males and 533 females. Female casualties were older (median age 29 vs. 25), less likely to have sustained injuries from explosives (48.0% vs. 56.8%), and more severely injured as measured by median composite injury scores (10 vs. 9). Most subjects were in Afghanistan for both females and males (52.9% vs. 73.9%). Among United States (US) service members, findings were similar to the overall study population, except female service members had lower median composite injury scores than males (5 vs. 9). In unadjusted analyses, females were less likely to survive to hospital discharge (OR 0.68, 95% CI 0.48-0.97). There was no difference in survival (OR 0.73, 95% CI 0.50-1.07), when controlling for confounders. In both unadjusted and adjusted analyses specific to US forces, we were unable to detect any differences in survival or for select analgesic administration. In both unadjusted and adjusted analyses specific to host nation civilians, we were unable to detect any differences in survival; however, even when controlling for confounders females were less likely to receive ketamine and IV morphine (OR 0.31, 95% CI 0.15-0.63; 0.69, 95% CI 0.49-0.98, respectively).

CONCLUSIONS: Females accounted for a small proportion of total casualties within our dataset. After controlling for confounders, survival was comparable between males and females, but host nation females were less likely to receive ketamine and intravenous morphine. Future studies should seek to elucidate the reasons for these subtle differences between males and females in prehospital combat casualty care.

J Trauma Acute Care Surg. 2019 May;86(5):864-870

# The why and how our trauma patients die: A prospective Multicenter Western Trauma Association study.

Callcut R, Kornblith L, Conroy A, Robles A, Meizoso J, Namias N, Meyer D, Haymaker A, Truitt M, Agrawal V, Haan J, Lightwine K, Porter J, San Roman J, Biffl W, Hayashi M, Sise M, Badiee J, Recinos G, Inaba K, Schroeppel T, Callaghan E, Dunn J, Godin S, McIntyre R Jr, Peltz E, OʼNeill P, Diven C, Scifres A, Switzer E, West M, Storrs S, Cullinane D, Cordova J, Moore E, Moore H, Privette A, Eriksson E, Cohen M; Western Trauma Association Multicenter Study Group.

BACKGROUND: Historically, hemorrhage has been attributed as the leading cause (40%) of early death. However, a rigorous, real-time classification of the cause of death (COD) has not been performed. This study sought to prospectively adjudicate and classify COD to determine the epidemiology of trauma mortality.

METHODS: Eighteen trauma centers prospectively enrolled all adult trauma patients at the time of death during December 2015 to August 2017. Immediately following death, attending providers adjudicated the primary and contributing secondary COD using standardized definitions. Data were confirmed by autopsies, if performed.

RESULTS: One thousand five hundred thirty-six patients were enrolled with a median age of 55 years (interquartile range, 32-75 years), 74.5% were male. Penetrating mechanism (n = 412) patients were younger (32 vs. 64, p < 0.0001) and more likely to be male (86.7% vs. 69.9%, p < 0.0001). Falls were the most common mechanism of injury (26.6%), with gunshot wounds second (24.3%). The most common overall primary COD was traumatic brain injury (TBI) (45%), followed by exsanguination (23%). Traumatic brain injury was nonsurvivable in 82.2% of cases. Blunt patients were more likely to have TBI (47.8% vs. 37.4%, p < 0.0001) and penetrating patients exsanguination (51.7% vs. 12.5%, p < 0.0001) as the primary COD. Exsanguination was the predominant prehospital (44.7%) and early COD (39.1%) with TBI as the most common later. Penetrating mechanism patients died earlier with 80.1% on day 0 (vs. 38.5%, p < 0.0001). Most deaths were deemed disease-related (69.3%), rather than by limitation of further aggressive care (30.7%). Hemorrhage was a contributing cause to 38.8% of deaths that occurred due to withdrawal of care.

CONCLUSION: Exsanguination remains the predominant early primary COD with TBI accounting for most deaths at later time points. Timing and primary COD vary significantly by mechanism. Contemporaneous adjudication of COD is essential to elucidate the true understanding of patient outcome, center performance, and future research.

LEVEL OF EVIDENCE: Epidemiologic, level II.

J Trauma Acute Care Surg. 2019 Apr 25. doi: 10.1097/TA.0000000000002349. [Epub ahead of print]

# Winds of Change in Military Medicine and Combat Casualty Care.

Davis M, Rasmussen T

NO ABSTRACT AVAILABLE

J Trauma Acute Care Surg. 2019 Feb;86(2):368-369

# Next-level thinking about mass casualty care.

Dutton R

QUOTE:"Seen in this light, the work by Lozado et al. falls in the middle of the science progressiontriangle—the trauma system level. The authors found that the postevent surge in blood donationwas too late to help the victims—because death from hemorrhage occurs in the first hours afterinjury 9—and led to the unfortunate waste of a precious resource. They advocate for a change in public rhetoric following mass-casualty events, combined with a prospective system for redirecting societal motivation into scheduled blood donations over the ensuing months.While it is hard to argue with the methodology or results of this work, it is worth a brief consideration of how generalizable the findings might be. Overall, medical outcomes of the Las Vegas shooting were better than expected. Patients reached definitive care quickly, in-hospital triage was relatively accurate and adequate resources were available. Sunrise Hospital was able to open a dozen operating rooms within hours of the event (S. Davidson, personal communication).

In many ways, the system got lucky: confusion in the EMS transport network was offset by the presence of multiple trauma centers; failure of the cell phone network was mitigated by public news broadcasts describing the magnitude of the event, enabling spontaneous return to the hospital of off-duty personnel; Sunday-night blood supplies were at their weekly high, and occurrence of the event just before evening change-of-shift made it easy to keep additional staff."

JAMA Surg. 2019;Epub ahead of print

# Use of Combat Casualty Care Data to Assess the US Military Trauma System During the Afghanistan and Iraq Conflicts, 2001-2017.

Howard J, Kotwal R, Turner C, Janak J, Mazuchowski E, Butler F, Stockinger Z, Holcomb B, Bono R, Smith D

Importance: Although the Afghanistan and Iraq conflicts have the lowest US case-fatality rates in history, no comprehensive assessment of combat casualty care statistics, major interventions, or risk factors has been reported to date after 16 years of conflict.

Objectives: To analyze trends in overall combat casualty statistics, to assess aggregate measures of injury and interventions, and to simulate how mortality rates would have changed had the interventions not occurred.

Design, Setting, and Participants: Retrospective analysis of all available aggregate and weighted individual administrative data compiled from Department of Defense databases on all 56 763 US military casualties injured in battle in Afghanistan and Iraq from October 1, 2001, through December 31, 2017. Casualty outcomes were compared with period-specific ratios of the use of tourniquets, blood transfusions, and transport to a surgical facility within 60 minutes. Main Outcomes and Measures: Main outcomes were casualty status (alive, killed in action [KIA], or died of wounds [DOW]) and the case-fatality rate (CFR). Regression, simulation, and decomposition analyses were used to assess associations between covariates, interventions, and individual casualty status; estimate casualty transitions (KIA to DOW, KIA to alive, and DOW to alive); and estimate the contribution of interventions to changes in CFR.

Results: In aggregate data for 56 763 casualties, CFR decreased in Afghanistan (20.0% to 8.6%) and Iraq (20.4% to 10.1%) from early stages to later stages of the conflicts. Survival for critically injured casualties (Injury Severity Score, 25-75 [critical]) increased from 2.2% to 39.9% in Afghanistan and from 8.9% to 32.9% in Iraq. Simulations using data from 23 699 individual casualties showed that without interventions assessed, CFR would likely have been higher in Afghanistan (15.6% estimated vs 8.6% observed) and Iraq (16.3% estimated vs 10.1% observed), equating to 3672 additional deaths (95% CI, 3209-4244 deaths), of which 1623 (44.2%) were associated with the interventions studied: 474 deaths (12.9%) (95% CI, 439-510) associated with the use of tourniquets, 873 (23.8%) (95% CI, 840-910) with blood transfusion, and 275 (7.5%) (95% CI, 259-292) with prehospital transport times.

Conclusions and Relevance: Our analysis suggests that increased use of tourniquets, blood transfusions, and more rapid prehospital transport were associated with 44.2% of total mortality reduction. More critically injured casualties reached surgical care, with increased survival, implying improvements in prehospital and hospital care.

Mil Med. 2019 Mar 1;184(Suppl 1):133-137. doi: 10.1093/milmed/usy311.

# Prehospital Interventions Performed in Afghanistan Between November 2009 and March 2014.

Lairet J, Bebarta V, Maddry J, Reeves L, Mora A, Blackbourne L(6), Rasmussen T(7).

OBJECTIVE: Care provided to a casualty in the prehospital combat setting can influence subsequent medical interactions and impact patient outcomes; therefore, we aimed to describe the incidence of specific prehospital interventions (lifesaving interventions (LSIs)) performed during the resuscitation and transport of combat casualties.

METHODS: We performed a prospective observational, IRB approved study between November 2009 and March 2014. Casualties were enrolled as they were cared for at nine U.S. military medical facilities in Afghanistan. Data were collected using a standardized collection form. Determination if a prehospital intervention was performed correctly, performed incorrectly, or was necessary but was not performed (missed LSIs) was made by the receiving facility's medical provider.

RESULTS: Two thousand one hundred and six patients met inclusion criteria. The mean age was 25 years and 98% were male. The most common mechanism of injury was explosion 57%. There were 236 airway interventions attempted, 183 chest procedures, 1,673 hemorrhage control, 1,698 vascular access, and 1,066 hypothermia preventions implemented. There were 142 incorrectly performed interventions and 360 were missed.

CONCLUSIONS: In our study, the most commonly performed prehospital LSI in a combat setting were for vascular access and hemorrhage control. The most common incorrectly performed and missed interventions were airway interventions and chest procedures respectively.

J Spec Oper Med. Spring 2019;19(1):20-22.

# Versatility With Far Forward Damage Control Surgery: Successful Resuscitative Thoracotomy in an HH-60 Black Hawk.

Pieper M, Vonderharr M, Knutson T, Sullivan J, Allison C, Englert Z

The military conflicts of the past 17 years have taught us many lessons, including the evolution of the tiered trauma system with en route resuscitation. The evolution of the conflict has begun to limit the reach of this standard trauma system. Recent evidence suggests that 95% of early deaths resulting from traumatic injuries may be prevented if the patient can undergo damage control surgery within 23 minutes of injury. US Military Surgical Resuscitation Teams have been developed to shorten this time from injury to surgical care, as illustrated by this case report.

J Vasc Surg. 2019 Jul;70(1):224-232

# Management and outcome of 597 wartime penetrating lower extremity arterial injuries from an international military cohort.

Sharrock A, Tai N, Perkins Z, White J, Remick K, Rickard R, Rasmussen T

OBJECTIVE: Vascular injury is a leading cause of death and disability in military and civilian settings. Most wartime and an increasing amount of civilian vascular trauma arises from penetrating mechanisms of injury due to gunshot or explosion. The objective of this study was to provide a comprehensive examination of penetrating lower extremity arterial injury and to characterize long-term limb salvage and differences related to mechanisms of injury.

METHODS: The military trauma registries of the United States and the United Kingdom were analyzed to identify service members who sustained penetrating lower limb arterial injury (2001-2014). Treatment and limb salvage data were studied and comparisons made of patients whose penetrating vascular trauma arose from explosion (group 1) vs gunshot (group 2). Standardized statistical testing was used, with Bonferroni corrections for multiple comparisons.

RESULTS: The cohort consisted of 568 combat casualties (mean age, 25.2 years) with 597 injuries (explosion, n = 416; gunshot, n = 181). Group 1 had higher Injury Severity Score (P < .05) and Mangled Extremity Severity Score (P < .0001), required more blood transfusion (P < .05), and had more tibial (P < .01) and popliteal (P < .05) arterial injuries; group 2 had more profunda femoris injuries (P < .05). Initial surgical management for the whole cohort included vein interposition graft (33%), ligation (31%), primary repair with or without patch angioplasty (16%), temporary vascular shunting (15%), and primary amputation (6%). No difference in patency of arterial reconstruction was found between group 1 and group 2, although group 1 had a higher incidence of primary (13% vs 2%; P < .05) and secondary (19% vs 9%; P < .05) amputation. Similarly, longer term freedom from amputation was lower for group 1 than for group 2 (68% vs 89% at 5.5 years; Cox hazard ratio, 0.30; P < .0001), as was physical functioning (36-Item Short Form Health Survey data; mean, 39.80 vs 43.20; P < .05).

CONCLUSIONS: The majority of wartime lower extremity arterial injuries result from an explosive mechanism that preferentially affects the tibial vasculature and results in poorer long-term limb salvage compared with those injured with firearms. The mortality associated with immediate limb salvage attempts is low, and delayed amputations occur weeks later, affording the patient involvement in the decision-making and rehabilitation planning. We recommend assertive attempts at vascular repair and limb salvage for service members injured by explosive and gunshot mechanisms.

J Am Coll Surg. 2019 Sep;229(3):244-251

# Incidence and Cause of Potentially Preventable Death after Civilian Public Mass Shooting in the US.

Smith E, Sarani B, Shapiro G, Gondek S, Rivas L, Ju T, Robinson B, Estroff J, Fudenberg J, Amdur R, Mitchell R

BACKGROUND: The incidence and severity of civilian public mass shooting (CPMS) events continue to rise. Understanding the wounding pattern and incidence of potentially preventable death (PPD) after CPMS is key to updating prehospital response strategy.

METHODS: A retrospective study of autopsy reports after CPMS events identified via the Federal Bureau of Investigation CPMS database from December 1999 to December 31, 2017 was performed. Sites of injury, fatal injury, and incidence of PPD were determined independently by a multidisciplinary panel composed of trauma surgery, emergency medicine, critical care paramedicine, and forensic pathology.

RESULTS: Nineteen events including 213 victims were reviewed. Mean number of gunshot wounds per victim was 4.1. Sixty-four percent of gunshots were to the head and torso. The most common cause of death was brain injury (52%). Only 12% (26 victims) were transported to the hospital and the PPD rate was 16% (34 victims). The most commonly injured organs in those with PPD were the lung (59%) and spinal cord (24%). Only 1% of PPD victims had a gunshot to a vascular structure in an extremity.

CONCLUSIONS: The PPD rate after CPMS is high and is due mostly to non-hemorrhaging chest wounds. Prehospital care strategy should focus on immediate point of wounding care by both laypersons and medical personnel, as well as rapid extrication of victims to definitive medical care.

Mil Med. 2019 Jun 27. pii: usz158. doi: 10.1093/milmed/usz158

# Heterogeneity in Military Trauma Casualty Care.

Englert Z, Kinard J, Qureshi I, Glaser J, Hall A

INTRODUCTION: Military combat casualty care is at the forefront of military medical readiness, but there is little data on current proficiency of deployed personnel. A previous study identified a potential performance gap in military trauma teams. This study aims to evaluate a subsequent team to determine if heterogeneity of teams exists and to determine if this level of efficiency persists or can be improved.

MATERIALS AND METHODS: Military trauma teams at the Role 3 hospital in Bagram, Afghanistan, were evaluated over the course of a single deployment between April and October 2018. Trauma teams were directly observed and performance of the ATLS primary trauma survey timed. These results were compared to previously published times from Kandahar and Bagram Role 3 sites from Oct 2016 to Apr 2017.

RESULTS: Time to completion of the primary survey in 2018 was statistically faster than the times reported from the Role 3 sites from Oct 2016 to Apr 2017 (344.75 s vs. 482.8 s, p < 0.05). The greatest improvements of efficiency were in the time periods between assessing the airway and breathing, evaluating the patient's circulation, and completing of the primary survey.

CONCLUSIONS: Trauma teams can vary significantly in their efficiency in evaluating trauma patients. Whether this is clinically significant is currently debatable, but it highlights a possible readiness gap for deploying military personnel and the heterogeneity of military combat casualty care.

J Trauma Acute Care Surg. 2019 Sep;87(3):645-657

# A descriptive study of US Special Operations Command fatalities, 2001 to 2018.

Kotwal R, Mazuchowski E, Stern C, Montgomery H, Janak J, Howard J, Butler F, Holcomb J, Eastridge B, Gurney J, Shackelford S

BACKGROUND: Studies of fatalities from injury and disease guide prevention and treatment efforts for populations at risk. Findings can inform leadership and direct clinical practice guidelines, research, and personnel, training, and equipment requirements.

METHODS: A retrospective review and descriptive analysis was conducted of United States Special Operations Command (USSOCOM) fatalities who died while performing duties from September 11, 2001, to September 10, 2018. Characteristics analyzed included subcommand, military activity, operational posture, and manner of death.

RESULTS: Of 614 USSOCOM fatalities (median age, 30 years; male, 98.5%) the leading cause of death was injury (97.7%); specifically, multiple/blunt force injury (34.5%), blast injury (30.7%), gunshot wound (GSW; 30.3%), and other (4.5%). Most died outside the United States (87.1%), during combat operations (85.3%), in the prehospital environment (91.5%), and the same day of insult (90.4%). Most fatalities were with the US Army Special Operations Command (67.6%), followed by the Naval Special Warfare Command (16.0%), Air Force Special Operations Command (9.3%), and Marine Corps Forces Special Operations Command (7.2%). Of 54.6% who died of injuries incurred during mounted operations, most were on ground vehicles (53.7%), followed by rotary-wing (37.3%) and fixed-wing (9.0%) aircrafts. The manner of death was primarily homicide (66.0%) and accident (30.5%), followed by natural (2.1%), suicide (0.8%), and undetermined (0.7%). Specific homicide causes of death were GSW (43.7%), blast injury (42.2%), multiple/blunt force injury (13.8%), and other (0.2%). Specific accident causes of death were multiple/blunt force injury (80.7%), blast injury (6.4%), GSW (0.5%), and other (12.3%). Of accident fatalities with multiple/blunt force injury, the mechanism was mostly aircraft mishaps (62.9%), particularly rotary wing (68.4%).

CONCLUSION: Most USSOCOM fatalities died abroad from injury in the prehospital setting. To improve survival from military activities worldwide, leaders must continue to optimize prehospital capability and develop strategies that rapidly connect patients to advanced resuscitative and surgical care.

LEVEL OF EVIDENCE: Epidemiological, level IV; Therapeutic level IV.

Ann Vasc Surg. 2019 Jul 22;Epub ahead of print

# Epidemiology of Upper Extremity Vascular Injury in Contemporary Combat.

Vuoncino M, Soo Hoo A, Patel J, White P, Rasmussen T, White J.

BACKGROUND: The incidence of wartime upper-extremity vascular injury (UEVI) has been stable for the past century. The objective of this study is to provide a contemporary review of wartime UEVI, including epidemiologic characterization and description of early limb loss.

METHODS: The Department of Defense Trauma Registry (DoDTR) was queried to identify US service members who sustained a battle-related UEVI in Afghanistan between January 2009 and December 2015. Anatomic distribution of injury, mechanism of injury (MOI), associated injuries, early management, and early limb loss were analyzed.

RESULTS: Analysis identified 247 casualties who sustained 308 UEVIs. The most common injury was to the vessels distal to the brachial bifurcation (63.3%, n = 195), followed by the brachial vessels (27.3%, n = 84) and the axillary vessels (9.4%, n = 29). The predominant MOIs were penetrating explosive fragments (74.1%, n = 183) and gunshot wounds (25.9%, n = 64). Associated fractures were identified in 151 (61.1%) casualties and nerve injuries in 133 (53.8%). Angiography was performed in 91 (36.8%) casualties, and endovascular treatment was performed 10 (4%) times. Temporary vascular shunts were placed in 39 (15.8%) casualties. Data on surgical management were available for 171 injuries and included repair (48%, n = 82) and ligation (52%, n = 89). The early limb loss rate was 12.1% (n = 30). For all casualties sustaining early limb loss, the MOI was penetrating fragments from an explosion; the average injury severity score (ISS) was 32.3, and the mortality was 6.7% (n = 2). In those without amputation, the ISS and mortality were low at 20 and 4.6% (n = 10), respectively. Overall mortality was 4.9% (n = 12).

CONCLUSIONS: The early limb loss rate was increased compared with initial descriptions from Operation Iraqi Freedom. Amputations are associated with a higher ISS. Improved data capture and fidelity, or differing MOIs, may account for this trend. Proficiency with open and endovascular therapy remains a critical focus for combat casualty care.

J Spec Oper Med. Winter 2017;17(4):68-71.

# Experience With Prehospital Damage Control Capability in Modern Conflict: Results From Surgical Resuscitation Team Use.

DuBose J, Martens D, Frament C, Haque I, Telian S, Benson P

BACKGROUND: Early resuscitation and damage control surgery (DCS) are critical components of modern combat casualty care. Early and effective DCS capabilities can be delivered in a variety of settings through the use of a mobile surgical resuscitation team (SRT).

METHODS: Twelve years of after-action reports from SRTs were reviewed. Demographics, interventions, and outcomes were analyzed.

RESULTS: Data from 190 casualties (185 human, five canine) were reviewed. Among human casualties, 12 had no signs of life at intercept and did not survive. Of the remaining 173 human casualties, 96.0% were male and 90.8% sustained penetrating injuries. Interventions by the SRT included intravascular access (50.9%) and advanced airway establishment (29.5%). Resuscitation included whole blood (3.5%), packed red blood cells (20.8%), and thawed plasma (11.0%). Surgery was provided for 63 of the 173 human casualties (36.4%), including damage control laparotomy (23.8%) and arterial injury shunting or repair (19.0%). SRTs were effectively used to augment an existing medical treatment facility (70.5%), to facilitate casualty transport (13.3%), as an independent surgical entity at a forward ground structure (9.2%), and in mobile response directly to the point of injury (6.9%). Overall survival was 97.1%.

CONCLUSION: An SRT provides a unique DCS capability that can be successfully used in a variety of flexible roles.

Mil Med. 2019 Jul 1;184(7-8):e236-e246

# Reconstructing the Face of War.

Farber S, Latham K, Kantar R, Perkins J, Rodriguez E

INTRODUCTION: Ongoing combat operations in Iraq, Afghanistan, and other theaters have led to an increase in high energy craniomaxillofacial (CMF) wounds. These challenging injuries are typically associated with complex tissue deficiencies, evolving areas of necrosis, and bony comminution with bone and ballistic fragment sequestrum. Restoring form and function in these combat-sustained CMF injuries is challenging, and frequently requires local and distant tissue transfers. War injuries are different than the isolated trauma seen in the civilian sector. Donor sites are limited on patients with blast injuries and they may have preferences or functional reasons for the decisions to choose flaps from the available donor sites.

METHODS: A case series of patients who sustained severe combat-related CMF injury and were treated at Walter Reed National Military Medical Center (WRNMMC) is presented. Our study was exempt from Institutional Review Board review, and appropriate written consent was obtained from all patients included in the study for the use of representative clinical images.

RESULTS: Four patients treated by the CMF team at Walter Reed National Military Medical Center are presented. In this study, we highlight their surgical management by the CMF team at WRNMMC, detail their postoperative course, and illustrate the outcomes achieved using representative patient clinical images. We also supplement this case series demonstrating military approaches to complex CMF injuries with CMF reconstructive algorithms utilized by the senior author (EDR) in the management of civilian complex avulsive injuries of the upper, mid, and lower face are thoroughly reviewed.

CONCLUSION: While the epidemiology and characteristics of military CMF injuries have been well described, their management remains poorly defined and creates an opportunity for reconstructive principles proven in the civilian sector to be applied in the care of severely wounded service members. The War on Terror marks the first time that microsurgery has been used extensively to reconstruct combat sustained wounds of the CMF region. Our manuscript reviews various options to reconstruct these devastating CMF injuries and emphasizes the need for steady communication between the civilian and military surgical communities to establish the best care for these complex patients.

J Emerg Med. 2019 Nov;57(5):646-652

# An Analysis of Adherence to Tactical Combat Casualty Care Guidelines for the Administration of Tranexamic Acid.

Fisher A, Carius B, April M, Naylor J, Maddry J, Schauer S

BACKGROUND: Hemorrhage is the leading cause of potentially survivable deaths in combat. Previous research demonstrated that tranexamic acid (TXA) administration decreased mortality among casualties. For casualties expected to receive a transfusion, the Committee on Tactical Combat Casualty Care (TCCC) recommends TXA. Despite this, the use and adherence of TXA in the military prehospital combat setting, in accordance with TCCC guidelines, is low.

OBJECTIVES: We sought to analyze TXA administration and use among combat casualties reasonably expected to require blood transfusion, casualties with tourniquet placement, amputations, and gunshot wounds.

METHODS: Based on TCCC guidelines, we measured proportions of patients receiving prehospital TXA: casualties undergoing tourniquet placement, casualties sustaining amputation proximal to the phalanges, patients sustaining gunshot wounds, and patients receiving ≥10 units of blood products within 24 h of injury. Univariable and multivariable analyses were also completed.

RESULTS: Within our dataset, 255 subjects received TXA. Four thousand seventy-one subjects had a tourniquet placed, of whom 135 (3.3%) received prehospital TXA; 1899 subjects had an amputation proximal to the digit with 106 (5.6%) receiving prehospital TXA; and 6660 subjects had a gunshot wound with 88 (1.3%) receiving prehospital TXA. Of 4246 subjects who received ≥10 units of blood products within the first 24 h, 177 (4.2%) received prehospital TXA.

CONCLUSIONS: We identified low TXA administration despite TCCC recommendations. Future studies should seek to both identify reasons for limited TXA administration and methods to increase future utilization.

J Spec Oper Med. 2019 Fall;19(3):110-115.

# United States Military Parachute Injuries. Part 1: Early Airborne History and Secular Trends in Injury Incidence.

Knapik J

This article traces the early history of military airborne operations and examines studies that have provided overall incidences of parachute-related injuries over time. The first US combat parachute assault was proposed during World War I, but the war ended before the operation could be conducted. Experimental jumps were conducted near San Antonio, Texas, in 1928 and 1929, but it was not until 1939, spurred by the developments in Germany, that the US Army Chief of Infantry proposed the development of an "air infantry." An Airborne Test Platoon was instituted with 48 men at Fort Benning, Georgia, and mass training of paratroopers began in 1940. The US entered World War II in December 1941 with the attack on Pearl Harbor and declaration of war by Germany. In January 1942, US War Department directed that four parachute regiments be formed. The 509th Parachute Infantry Battalion made the first US Army combat jumps into Morocco and Algeria in November 1942. At the US Army Airborne School in the 1940-1941 period, the parachute-related injury incidence was 27 injuries/1000 jumps; by 1993 it was 10 injuries/1000 jumps and in 2005-2006, 6 injuries/1000 jumps. Analysis of time-loss injuries in operational units showed a decline in injuries from 6 injuries/1000 jumps to 3 injuries/1000 jumps to 1 injury/1000 jumps in the periods 1946-1949, 1956-1962, and 1962-1963, respectively. When all injuries (not just time-loss) experienced in operational units are considered, the overall injury incidence was about 8 injuries/1000 jumps in the 1993- 2013 period. In jump operations involving a larger number of risk factors (e.g., high winds, combat loads, rough drop zones) injury incidences was considerably higher. The few studies that have reported on parachute-related injuries in combat operations suggest injury incidence ranged from 19 to 401 injuries/ 1000 jumps, likely because of the number of known injury risk factors present during these jumps. Despite the limitations of this analysis stemming from different injury definitions and variable risk factors, the data strongly suggest that military parachute injuries have sharply declined over time. Part 2 of this series will discuss techniques and equipment that have likely improved the safety of parachute operations.

J Trauma Acute Care Surg. 2019 Oct;87(4):978-989

# Influence of prehospital physician presence on survival after severe trauma: Systematic review and meta-analysis.

Knapp J, Häske D, Böttiger B, Limacher A, Stalder O, Schmid A, Schulz S, Bernhard M.

BACKGROUND: As trauma is one of the leading causes of death worldwide, there is great potential for reducing mortality in trauma patients. However, there is continuing controversy over the benefit of deploying emergency medical systems (EMS) physicians in the prehospital setting. The objective of this systematic review and meta-analysis is to assess how out-of-hospital hospital management of severely injured patients by EMS teams with and without physicians affects mortality.

METHODS: PubMed and Google Scholar were searched for relevant articles, and the search was supplemented by a hand search. Injury severity in the group of patients treated by an EMS team including a physician had to be comparable to the group treated without a physician. Primary outcome parameter was mortality. Helicopter transport as a confounder was accounted for by subgroup analyses including only the studies with comparable modes of transport. Quality of all included studies was assessed according to the Cochrane handbook.

RESULTS: There were 2,249 publications found, 71 full-text articles assessed, and 22 studies included. Nine of these studies were matched or adjusted for injury severity. The odds ratio (OR) of mortality was significantly lower in the EMS physician-treated group of patients: 0.81; 95% confidence interval (CI): 0.71-0.92. When analysis was limited to the studies that were adjusted or matched for injury severity, the OR was 0.86 (95% CI, 0.73-1.01). Analyzing only studies published after 2005 yielded an OR for mortality of 0.75 (95% CI, 0.64-0.88) in the overall analysis and 0.81 (95% CI, 0.67-0.97) in the analysis of adjusted or matched studies. The OR was 0.80 (95% CI, 0.65-1.00) in the subgroup of studies with comparable modes of transport and 0.74 (95% CI, 0.53-1.03) in the more recent studies.

CONCLUSION: Prehospital management of severely injured patients by EMS teams including a physician seems to be associated with lower mortality. After excluding the confounder of helicopter transport we have shown a nonsignificant trend toward lower mortality.

LEVEL OF EVIDENCE: Systematic review and meta-analysis, level III.