High Bilateral Amputations and Dismounted Complex Blast Injury

Summary of Changes

1. Inclusion of data from the DoD Trauma Registry (DoDTR) on incidence/prevalence and resuscitation requirements of this unique population.
2. Considerations for Zone 3 resuscitative endovascular balloon occlusion of the aorta (REBOA) for proximal control in casualties with high bilateral amputations.
3. Updated initial transfusion requirements and guidelines. Whole blood should be used preferentially, and crystalloid should not be used for resuscitation of these patients secondary to their profound shock state.
4. Clarified PI metrics to include the addition of:
   - Number/percentage of patients who undergo REBOA placement upon arrival to the medical treatment facility (MTF).
   - Documentation and tracking of transfusion requirements.
   - Use standardized OR sheet to be included in notes to Performance/Adherence Metrics (Appendix A: DCBI H&P supplement).
5. Rapid Update: 2 April 2026 PI Metrics updated

BACKGROUND

The Dismounted Complex Blast Injury (DCBI) injury is a devastating trauma incurred when a casualty operating in a foot patrol posture either steps on or is in extremely close proximity to an improvised explosive device (IED)/buried explosive. These injuries were common during 'cordon and knock’ operations in Afghanistan from 2010 to 2012. During this type of operation, counterinsurgency forces assemble around an area to provide security ("cordon") and then obtain permission to search the area from residents ("knock"). The relative decreased physical protection of troops on foot patrols put service members at risk for these injury patterns.

In 2011, active engagement with senior military leaders on these devastating injury patterns changed tactics, techniques, and procedure. An ad hoc committee was established that produced a DCBI report, Report of the Army Dismounted Complex Blast Injury Task Force, which influenced changes in military tactics and demonstrates the criticality and power of rapid cycling of clinical data to not just impact clinical care and the trauma system but change operational policy and military tactics.1,2

While this injury pattern has been less common over the last 10 years, it still exists and will likely exist in future combat scenarios. Every military medical provider must know its role in the management of these critically injured service members, as every minute matters given how rapidly these causalities die from hemorrhage.

The DCBI pattern of injuries consists of:

- bilateral (generally proximal) lower extremity amputations
- pelvic/perineal injuries to include testicular and penile injuries
- usually, an upper extremity amputation/injury
- open pelvic fractures
- spinal fractures, more commonly of the sacral and lumbar spines as extension from lower extremity axial loading
- thoraco-abdominal injuries, though less likely (but must be ruled out with imaging)

DCBI represents one of the most challenging cohorts of surgical patients to manage from time of initial injury through definitive reconstruction. These injuries are associated with a high incidence of both physical and psychological morbidity, as well as mortality. Survival is initially contingent upon rapid hemorrhage control and massive transfusion being delivered in <40 minutes, through well-resourced and rehearsed resuscitation protocols.3 A coordinated team approach is essential to provide hemorrhage control and whole blood resuscitation. If low titer O+ whole blood (LTOWB) is not immediately available, then using a balanced component resuscitation is essential while either type specific or low liter Group O fresh whole blood is being obtained from a Walking Blood Bank (WBB). Airway management is less of a priority in these casualties unless they have an airway injury or a significantly altered level of consciousness affecting the casualty’s ability to protect their own airway. Hemorrhagic shock results in mortality in these patients; early focus on airway interventions comes at the risk of wasting minutes that must be focused on blood resuscitation. Keep in mind that the initial decreased mental status in these patients is most likely secondary to severe blood loss and shock. Inducing general anesthesia, intubating these casualties, and providing positive pressure ventilation prior to resuscitation will result in cardiovascular collapse. Initial airway management should be performed with a nasopharyngeal airway and ventilation assist; simultaneous airway management, volume resuscitation (ideally with Whole Blood (WB) or balanced ratio transfusions), and immediate control of life-threatening hemorrhage.4

Later risks for morbidity and mortality include sepsis, including invasive fungal infection, and multisystem organ dysfunction. These injuries can broadly be divided into two categories: those with a perineal/pelvic floor injury and those without. Counterparts or similar injury patterns in civilian trauma are rare. An organized, aggressive continuum of care from the Point of Injury (POI) onwards by medics, enroute care teams, anesthetists, general/trauma surgeons, orthopedic surgeons, and intensivists is critical to optimize outcomes in these devastating injuries.

#### Data

Data from the DoDTR on 385 casualties from 2010-2021 with bilateral lower extremity amputations secondary to DCBI were transfused an average of 45 units of blood in the first 24 hours, with the highest volume of blood recorded in a survivor from this injury being over 200 units of blood product.

Figure 1. DCBI injury examples