IMPORTANCE: Prehospital blood product transfusion in trauma care remains controversial due to poor-quality evidence and cost. Sequential expansion of blood transfusion capability after 2012 to ...deployed military medical evacuation (MEDEVAC) units enabled a concurrent cohort study to focus on the timing as well as the location of the initial transfusion. OBJECTIVE: To examine the association of prehospital transfusion and time to initial transfusion with injury survival. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of US military combat casualties in Afghanistan between April 1, 2012, and August 7, 2015. Eligible patients were rescued alive by MEDEVAC from point of injury with either (1) a traumatic limb amputation at or above the knee or elbow or (2) shock defined as a systolic blood pressure of less than 90 mm Hg or a heart rate greater than 120 beats per minute. EXPOSURES: Initiation of prehospital transfusion and time from MEDEVAC rescue to first transfusion, regardless of location (ie, prior to or during hospitalization). Transfusion recipients were compared with nonrecipients (unexposed) for whom transfusion was delayed or not given. MAIN OUTCOMES AND MEASURES: Mortality at 24 hours and 30 days after MEDEVAC rescue were coprimary outcomes. To balance injury severity, nonrecipients of prehospital transfusion were frequency matched to recipients by mechanism of injury, prehospital shock, severity of limb amputation, head injury, and torso hemorrhage. Cox regression was stratified by matched groups and also adjusted for age, injury year, transport team, tourniquet use, and time to MEDEVAC rescue. RESULTS: Of 502 patients (median age, 25 years interquartile range, 22 to 29 years; 98% male), 3 of 55 prehospital transfusion recipients (5%) and 85 of 447 nonrecipients (19%) died within 24 hours of MEDEVAC rescue (between-group difference, −14% 95% CI, −21% to −6%; P = .01). By day 30, 6 recipients (11%) and 102 nonrecipients (23%) died (between-group difference, −12% 95% CI, −21% to −2%; P = .04). For the 386 patients without missing covariate data among the 400 patients within the matched groups, the adjusted hazard ratio for mortality associated with prehospital transfusion was 0.26 (95% CI, 0.08 to 0.84, P = .02) over 24 hours (3 deaths among 54 recipients vs 67 deaths among 332 matched nonrecipients) and 0.39 (95% CI, 0.16 to 0.92, P = .03) over 30 days (6 vs 76 deaths, respectively). Time to initial transfusion, regardless of location (prehospital or during hospitalization), was associated with reduced 24-hour mortality only up to 15 minutes after MEDEVAC rescue (median, 36 minutes after injury; adjusted hazard ratio, 0.17 95% CI, 0.04 to 0.73, P = .02; there were 2 deaths among 62 recipients vs 68 deaths among 324 delayed transfusion recipients or nonrecipients). CONCLUSIONS AND RELEVANCE: Among medically evacuated US military combat causalities in Afghanistan, blood product transfusion prehospital or within minutes of injury was associated with greater 24-hour and 30-day survival than delayed transfusion or no transfusion. The findings support prehospital transfusion in this setting.
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.
Secretary of Defense Robert Gates' 60-minute medevac mandate in 2009 halved patient transportation times and saved over 350 lives in Afghanistan.3 Personal protective equipment has improved - between ...my first and most recent deployment I have received better small arms protective insert plates, side small arms protective inserts, a new vest and helmet, shoulder and groin protectors, protective undergarments, and bottles of ibuprofen and talcum powder to mitigate the burden of all of the above. A civilian trauma system is an enduring thing, based upon permanent fixed facilities that can codify their improvements and mature over time; dedicated medical transportation assets that have no other role; with long-term staff and leadership, many of whose careers are centered on trauma care; functioning within a system that is focused on, if not exclusively, medical. How patients are treated should also be standardized, as exemplified by Tactical Combat Casualty Care (TCCC) and the highly successful JTS Clinical Practice Guidelines (CPGs) printed in this supplement, which have been shown to improve clinical outcomes.15,16 These are important if not critical to good care, especially when that care is provided by personnel whose jobs are not normally traumarelated. The JTS' operational cycle as seen in Figure 2 does this through clinical data collection and abstraction into a dedicated trauma registry, analysis of both individual and aggregated patient data to identify clinical problems and best practices, and then feeding those lessons learned and best practices back into daily patient care downrange, to restart the process and track improvement and change.
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Most combat casualties who die, do so in the prehospital setting. Efforts directed toward alleviating prehospital combat trauma death, known as killed in action (KIA) mortality, have the greatest ...opportunity for eliminating preventable death.
Four thousand five hundred forty-two military casualties injured in Afghanistan from September 11, 2001, to March 31, 2014, were included in this retrospective analysis to evaluate proposed explanations for observed KIA reduction after a mandate by Secretary of Defense Robert M. Gates that transport of injured service members occur within 60 minutes. Using inverse probability weighting to account for selection bias, data were analyzed using multivariable logistic regression and simulation analysis to estimate the effects of (1) gradual improvement, (2) damage control resuscitation, (3) harm from inadequate resources, (4) change in wound pattern, and (5) transport time on KIA mortality.
The effect of gradual improvement measured as a time trend was not significant (adjusted odds ratio AOR, 0.99; 95% confidence interval CI, 0.94-1.03; p = 0.58). For casualties with military Injury Severity Score of 25 or higher, the odds of KIA mortality were 83% lower for casualties who needed and received prehospital blood transfusion (AOR, 0.17; 95% CI, 0.06-0.51; p = 0.002); 33% lower for casualties receiving initial treatment by forward surgical teams (AOR, 0.67; 95% CI, 0.58-0.78; p < 0.001); 70%, 74%, and 87% lower for casualties with dominant injuries to head (AOR, 0.30; 95% CI, 0.23-0.38; p < 0.001), abdomen (AOR, 0.26, 95% CI, 0.19-0.36; p < 0.001) and extremities (AOR, 0.13; 95% CI, 0.09-0.17; p < 0.001); 35% lower for casualties categorized with blunt injuries (AOR, 0.65; 95% CI, 0.46-0.92; p = 0.01); and 39% lower for casualties transported within one hour (AOR, 0.61; 95% CI, 0.51-0.74; p < 0.001). Results of simulations in which transport times had not changed after the mandate indicate that KIA mortality would have been 1.4% higher than observed, equating to 135 more KIA deaths (95% CI, 105-164).
Reduction in KIA mortality is associated with early treatment capabilities, blunt mechanism, select body locations of injury, and rapid transport.
Therapy, level III.
Relatively few publications exist on surgical workload in the deployed military setting. This study analyzes US military combat surgical workload in Iraq and Afghanistan to gain a more thorough ...understanding of surgical training gaps and personnel requirements.
A retrospective analysis of the Department of Defense Trauma Registry was performed for all Role 2 (R2) and Role 3 (R3) military treatment facilities from January 2001 to May 2016. International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes were grouped into 18 categories based on functional surgical skill sets. The 189,167 surgical procedures identified were stratified by role of care, month, and year. Percentiles were calculated for the number of procedures for each skill set. A literature search was performed for publications documenting combat surgical workload during the same period.
A total of 23,548 surgical procedures were performed at R2 facilities, while 165,619 surgical procedures were performed at R3 facilities. The most common surgical procedures performed overall were soft tissue (37.5%), orthopedic (13.84%), abdominal (13.01%), and vascular (6.53%). The least common surgical procedures performed overall were cardiac (0.23%), peripheral nervous system (0.53%), and spine (0.34%).Mean surgical workload at any point in time clearly underrepresented those units in highly kinetic areas, at times by an order of magnitude or more. The published literature always demonstrated workloads well in excess of the 50th percentile for the relevant time period.
The published literature on combat surgical workload represents the high end of the spectrum of deployed surgical experience. These trends in surgical workload provide vital information that can be used to determine the manpower needs of future conflicts in ever-changing operational tempo environments. Our findings provide surgical types and surgical workload requirements that will be useful in surgical training and placement of medical assets in future conflicts.
Epidemiologic study, level III; Care management, level III.
Thoracic surgery constitutes 2.5% of surgical procedures performed in theater, but the skills required are increasingly foreign to military surgeons. This study examines thoracic surgical workload in ...Iraq and Afghanistan to help define surgical training gaps.
Retrospective analysis of Department of Defense Trauma Registry for all role 2 (R2) (forward surgical) and role 3 (R3) (theater) military facilities, from January 2002 to May 2016. The 95 thoracic surgical International Classification of Diseases-9th Rev.-Clinical Modification procedure codes were grouped into 10 categories based on anatomy or endoscopy. Select groups were further stratified by type of definitive procedure. Procedure groupings were determined and adjudicated by surgeon subject matter experts. Data analysis used Stata Version 15 (College Station, TX).
Of the total procedures, 5,301 were classified as thoracic surgical procedures and were included in the present study. The majority of thoracic surgical procedures (4,645 87.6%) were recorded as being performed at R3 medical treatment facilities (MTFs). The thoracic surgical procedures groups with the largest proportions were: bronchoscopy (39.1%), thoracotomy (16.9%), diaphragm (15.6%), and lung (11.4%). The most common lung procedure subgroup, aside from not otherwise specified, was segmentectomy (28.8%). The R3 MTFs recorded nearly five times the number of lung procedures compared with R2 MTFs; with R3 MTFs recording more than eight times the number of lobectomies compared with R2 MTFs. Thoracic workload was variable over the 15-year study period.
Thoracic surgical skills are necessary in the deployed environment to manage combat-related injuries. Given the current trends in training and specialization, development and sustainment of thoracic surgical skills is challenging in the deployed US trauma system and likely for other nations, and humanitarian surgical care as well. Current training and practice paradigms pose both training and sustainment challenges for surgeons who deploy to a combat zone.
Therapeutic/Care Management IV.
Abdominal surgery constitutes approximately 13% of surgical procedures performed for combat injuries. This study examines the frequencies and type of abdominal surgical procedures performed during ...recent US Military operations.
A retrospective analysis of the Department of Defense Trauma Registry was performed for all Role 2 (R2) and Role 3 (R3) medical treatment facilities (MTFs), from January 2002 to May 2016. The 273 International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes that were identified as abdominal surgical procedures were stratified into 24 groups based on anatomic and functional classifications and then grouped by whether they were laparoscopic. Procedure grouping and categorization were determined, and adjudicated if necessary, by subject matter experts. Data analysis used Stata version 14 (College Station, TX).
A total of 26,548 abdominal surgical procedures were identified at R2 and R3 MTFs. The majority of abdominal surgical procedures were reported at R3 facilities. The largest procedure group at both R2 and R3 MTFs were procedures involving the bowel. There were 18 laparoscopic procedures reported (R2: 4 procedures, R3: 14 procedures). Laparotomy not otherwise specified was the second largest procedure group at both R2 (1,060 24.55%) and R3 (4,935 22.2%) MTFs. Abdominal caseload was variable over the 15-year study period.
Surgical skills such as open laparotomy and procedures involving the bowel are crucial in war surgery. The abundance of laparotomy not otherwise specified may reflect inadequate documentation, or the plethora of second- and third-look operations and washouts performed for complex abdominal injuries. Traditional elective general surgical cases (gallbladder, hernia) were relatively infrequent. Laparoscopy was almost nonexistent. Open abdominal surgical skills therefore remain a necessity for the deployed US Military General Surgeons; this is at odds with the shifting paradigm from open to laparoscopic skills in stateside civilian and military hospitals.
Epidemiologic study, level III.
Vascular surgery constitutes approximately 6.5% of surgical procedures performed for combat injuries, yet general surgeons are increasingly unfamiliar with vascular surgery. This study examines the ...frequency and type of vascular surgical procedures performed during recent US Military operations from 2002 to 2016.
A retrospective analysis of the Department of Defense Trauma Registry was performed for all Role (R)2 and R3 medical treatment facilities (MTFs), from January 2002 to May 2016. A total of 106 International Classification of Diseases-9th Rev.-Clinical Modification (ICD-9-CM) procedure codes were categorized as vascular and were included in the present analysis. Procedure codes were separated by anatomic location and procedure type. Ligation as part of an amputation was excluded. Grafts were further subdivided by type: synthetic, autologous, and unknown. Procedure grouping and categorization were determined by subject matter experts. Data analysis used Stata Version 14 (College Station, TX).
A total of 25,816 vascular surgical procedures were identified at R2 and R3 MTFs. Role 3 MTFs reported more than four times the number of procedures compared to R2 MTFs. The most common anatomic locations documented were extremity (64.96%) and not otherwise specified (28.1%). The most common procedures overall were amputation (33.36%) and fasciotomy (18.83%). The most common graft type was autologous (68.87%), and the least common was synthetic (5.69%).
While amputation, fasciotomy, and ligation were the most common vascular procedures performed for combat trauma, the need for definitive repair including grafting is common at both R2 and R3 MTFs. Vascular surgery therefore remains a necessary skill set for the deployed US Military surgeon; military general surgeons need to train and sustain their vascular skills, including proficiency at amputation and fasciotomy.
Epidemiologic study, level III.
Reducing time from injury to care can optimize trauma patient outcomes. A previous study of prehospital transport of US military casualties during the Afghanistan conflict demonstrated the importance ...of time and treatment capability for combat casualty survival.
A retrospective descriptive analysis was conducted to analyze battlefield data collected on US military combat casualties during the Iraq conflict from March 19, 2003, to August 31, 2010. All casualties were analyzed by mortality outcome (killed in action, died of wounds, case fatality rate) and compared with Afghanistan conflict. Detailed data for those who underwent prehospital transport were analyzed for effects of transport time, injury severity, and blood transfusion on survival.
For the total population, percent killed in action (16.6% vs. 11.1%), percent died of wounds (5.9% vs. 4.3%), and case fatality rate (10.0 vs. 8.6) were higher for Iraq versus Afghanistan (p < 0.001). Among 1,692 casualties (mean New Injury Severity Score, 22.5; mortality, 17.6%) with detailed data, the injury mechanism included 77.7% from explosions and 22.1% from gunshot wounds. For prehospital transport, 67.6% of casualties were transported within 60 minutes, and 32.4% of casualties were transported in greater than 60 minutes. Although 97.0% of deaths occurred in critical casualties (New Injury Severity Score, 25-75), 52.7% of critical casualties survived. Critical casualties were transported more rapidly (p < 0.01) and more frequently within 60 minutes (p < 0.01) than other casualties. Critical casualties had lower mortality when blood was received (p < 0.01). Among critical casualties, blood transfusion was associated with survival irrespective of transport time within or greater than 60 minutes (p < 0.01).
Although data were limited, early blood transfusion was associated with battlefield survival in Iraq as it was in Afghanistan.
Performance improvement and epidemiological, level IV.
Whole Blood Transfusion Cap, Andrew P; Beckett, Andrew; Benov, Avi ...
Military medicine,
09/2018, Volume:
183, Issue:
suppl_2
Journal Article
Peer reviewed
Open access
Whole blood is the preferred product for resuscitation of severe traumatic hemorrhage. It contains all the elements of blood that are necessary for oxygen delivery and hemostasis, in nearly ...physiologic ratios and concentrations. Group O whole blood that contains low titers of anti-A and anti-B antibodies (low titer group O whole blood) can be safely transfused as a universal blood product to patients of unknown blood group, facilitating rapid treatment of exsanguinating patients. Whole blood can be stored under refrigeration for up to 35 days, during which it retains acceptable hemostatic function, though supplementation with specific blood components, coagulation factors or other adjuncts may be necessary in some patients. Fresh whole blood can be collected from pre-screened donors in a walking blood bank to provide effective resuscitation when fully tested stored whole blood or blood components are unavailable and the need for transfusion is urgent. Available clinical data suggest that whole blood is at least equivalent if not superior to component therapy in the resuscitation of life-threatening hemorrhage. Low titer group O whole blood can be considered the standard of care in resuscitation of major hemorrhage.
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