Amber L. Dougherty

Morphine Use after Combat Injury in Iraq and Post-Traumatic Stress Disorder

BACKGROUND Post-traumatic stress disorder (PTSD) is a common adverse mental health outcome among seriously injured civilians and military personnel who are survivors of trauma. Pharmacotherapy in the aftermath of serious physical injury or exposure to traumatic events may be effective for the secondary prevention of PTSD. METHODS We identified 696 injured U.S. military personnel without serious traumatic brain injury from the Navy-Marine Corps Combat Trauma Registry Expeditionary Medical Encounter Database. Complete data on medications administered were available for all personnel selected. The diagnosis of PTSD was obtained from the Career History Archival Medical and Personnel System and verified in a review of medical records. RESULTS Among the 696 patients studied, 243 received a diagnosis of PTSD and 453 did not. The use of morphine during early resuscitation and trauma care was significantly associated with a lower risk of PTSD after injury. Among the patients in whom PTSD developed, 61% received morphine; among those in whom PTSD did not develop, 76% received morphine (odds ratio, 0.47; P<0.001). This association remained significant after adjustment for injury severity, age, mechanism of injury, status with respect to amputation, and selected injury-related clinical factors. CONCLUSIONS Our findings suggest that the use of morphine during trauma care may reduce the risk of subsequent development of PTSD after serious injury.

Prevalence and Psychological Correlates of Traumatic Brain Injury in Operation Iraqi Freedom

ObjectiveTo describe the prevalence and psychological correlates of traumatic brain injury (TBI) among injured male combatants in the Iraq conflict. ParticipantsA total of 781 men injured during military combat between September 2004 and February 2005. Main Outcome MeasuresMental health diagnosis (ICD-9 290–319), particularly posttraumatic stress disorder and mood/anxiety disorders, assigned through November 2006. Results15.8% met criteria for TBI (13.4% mild, 2.4% moderate-severe TBI), 35.0% other head injury, and 49.2% non-head injury. Multivariate logistic regression suggested lower rates of posttraumatic stress disorder and mood/anxiety disorders among those with mild and moderate-severe TBI. ConclusionsThese findings could reflect a problem with differential diagnosis or, conversely, a low rate of self-presentation for symptoms. Further research is needed to elucidate the psychological consequences, clinical implications, and overall impact of TBI among military combat veterans.

Battlefield Extremity Injuries in Operation Iraqi Freedom

OBJECTIVE Extremity injuries account for the majority of wounds incurred during US armed conflicts. Information regarding the severity and short-term outcomes of patients with extremity wounds, however, is limited. The aim of the present study was to describe patients with battlefield extremity injuries in Operation Iraqi Freedom (OIF) and to compare characteristics of extremity injury patients with other combat wounded. PATIENTS AND METHODS Data were obtained from the United States Navy-Marine Corps Combat Trauma Registry (CTR) for patients who received treatment for combat wounds at Navy-Marine Corps facilities in Iraq between September 2004 and February 2005. Battlefield extremity injuries were classified according to type, location, and severity; patient demographic, injury-specific, and short-term outcome data were analysed. Upper and lower extremity injuries were also compared. RESULTS A total of 935 combat wounded patients were identified; 665 (71%) sustained extremity injury. Overall, multiple wounding was common (an average of 3 wounds per patient), though more prevalent amongst patients with extremity injury than those with other injury (75% vs. 56%, P<.001). Amongst the 665 extremity injury patients, 261 (39%) sustained injury to the upper extremities, 223 (34%) to the lower extremities, and 181 (27%) to both the upper and lower extremities. Though the total number of patients with upper extremity injury was higher than lower extremity injury, the total number of extremity wounds (n=1654) was evenly distributed amongst the upper and lower extremities (827 and 827 wounds, respectively). Further, lower extremity injuries were more likely than the upper extremity injuries to be coded as serious to fatal (AIS>2, P<.001). CONCLUSIONS Extremity injuries continue to account for the majority of combat wounds. Compared with other conflicts, OIF has seen increased prevalence of patients with upper extremity injuries. Wounds to the lower extremities, however, are more serious. Further research on the risks and outcomes associated with extremity injury is necessary to enhance the planning and delivery of combat casualty medical care.

Injury-Specific Correlates of Combat-Related Traumatic Brain Injury in Operation Iraqi Freedom

Background:The prevalence of traumatic brain injury (TBI) has increased during the wars in Iraq and Afghanistan compared with 20th century military conflicts. The aim of this study was to elucidate injury-specific correlates of combat-related TBI that have yet to be clearly defined. Participants:Predominately Marine US service members who sustained brain injuries in Iraq between March 2004 and April 2008 identified from clinical records completed in the theater of combat operations (n = 2074). Main Outcome Measures:Severity of TBI was classified as mild, moderate, or severe. Injury-specific factors, such as injury mechanism and type, were abstracted from the clinical records and were compared with severity of TBI. Results:Of all TBIs observed in the sample, 89% were mild. Higher severity of TBI was associated with an increased likelihood of sustaining the injury by gunshot and a lower likelihood of helmet use. Improvised explosive devices were associated with a preponderance of mild TBIs, and frequency of injuries in locations in addition to the head was highest among those with moderate and severe TBIs. Concomitant injuries to the spine/back were associated with blast injury mechanisms. Conclusions:Most incidents of TBI occurring during Operation Iraqi Freedom are mild in severity and a result of blast mechanisms. Multiple injuries were common, particularly as severity of TBI increased. Further research is needed to determine effects of combat-related TBI on rehabilitative and adverse health outcomes.

Visual dysfunction following blast-related traumatic brain injury from the battlefield.

Primary objective: To assess the occurrence of ocular and visual disorders following blast-related traumatic brain injury (TBI) in Operation Iraqi Freedom. Research design: Retrospective cohort study. Methods and procedures: A total of 2254 US service members with blast-related combat injuries were identified for analysis from the Expeditionary Medical Encounter Database. Medical record information near the point of injury was used to assess factors associated with the diagnosis of ocular/visual disorder within 12 months after injury, including severity of TBI. Main outcomes and results: Of 2254 service members, 837 (37.1%) suffered a blast-related TBI and 1417 (62.9%) had other blast-related injuries. Two-hundred and one (8.9%) were diagnosed with an ocular or visual disorder within 12 months after blast injury. Compared with service members with other injuries, odds of ocular/visual disorder were significantly higher for service members with moderate TBI (odds ratio (OR) = 1.58, 95% confidence interval (CI) = 1.02–2.45) and serious to critical TBI (OR = 14.26, 95% CI = 7.00–29.07). Conclusions: Blast-related TBI is strongly associated with visual dysfunction within 1 year after injury and the odds of disorder appears to increase with severity of brain injury. Comprehensive vision examinations following TBI in theatre may be necessary.

Combat versus civilian open tibia fractures: The effect of blast mechanism on limb salvage

BACKGROUND This study compares open tibia fractures in US Navy and US Marine Corps casualties from the current conflicts with those from a civilian Level I trauma center to analyze the effect of blast mechanism on limb-salvage rates. METHODS Data from the 28,646 records in the University of California San Diego Trauma Registry from 1985 to 2006 was compared with 2,282 records from the US Navy and US Marine Corps Combat Trauma Registry Expeditionary Medical Encounter Database for the period of March 2004 to August 2007. Injuries were categorized by Gustilo-Anderson (G-A) open fracture classification. Independent variables included age, gender, mechanism of injury including blast mechanisms, shock, blood loss, prehospital time, procedures, Injury Severity Score, length of stay, and Mangled Extremity Severity Score (MESS). Dependent variables included early or late amputation and mortality. RESULTS The civilian group had 850 open tibia fractures with 45 amputations; the military group had 21 amputation patients (3 bilateral) in 115 open tibia fractures. Military group patients were more severely injured, more likely have hypotension, and had a higher amputation rate for G-A IIIB and IIIC fractures then civilian group patients. Blast mechanism was seen in the majority of military group patients and was rare in the civilian group. MESS scores had poor sensitivity (0.46, 95% confidence interval: 0.29-0.64) in predicting the need for amputation in the civilian group; in the military group sensitivity was better (0.67, 95% confidence interval: 0.43-0.85), but successful limb salvage was still possible in most cases with an MESS score of ≥7 when attempted. CONCLUSION Despite current therapy, limb salvage for G-A IIIB and IIIC grades are significantly worse for open tibia fractures as a result of blast injury when compared with typical civilian mechanisms. MESS scores do not adequately predict likelihood of limb salvage in combat or civilian open tibia fractures.

Postconcussive Symptom Reporting Among US Combat Veterans With Mild Traumatic Brain Injury From Operation Iraqi Freedom

Objective:To examine the association between postconcussive symptoms and mild traumatic brain injury (MTBI) among combat veterans while adjusting for posttraumatic stress disorder (PTSD) and depression. Patients:Military personnel with provider-diagnosed MTBI (n = 334) or nonhead injury (n = 658) were identified from the Expeditionary Medical Encounter Database. Main Outcome Measures:Post-Deployment Health Assessments and Re-Assessments were used to examine postconcussive symptoms and self-rated health. Results:Personnel with MTBI were more likely to report headache (odds ratio [OR] = 3.37; 95% confidence interval [CI] = 2.19–5.17), back pain (OR = 1.79; 95% CI = 1.23–2.60), memory problems (OR = 1.86; 95% CI = 1.20–2.88), tinnitus (OR = 1.63; 95% CI = 1.10–2.41), and dizziness (OR = 2.13; 95% CI = 1.06–4.29) compared with those with non-head injuries. Among those with MTBI, self-reported decline in health was associated with memory problems (OR = 5.07; 95% CI = 2.56–10.02) and dizziness (OR = 10.60; 95% CI = 3.48–32.27). Conclusions:Mild traumatic brain injury is associated with reports of negative health consequences among combat veterans even when accounting for co-occurring psychological morbidity. The identification of postconcussive symptoms related to declines in a service members self-rated health may be important in targeting and prioritizing clinical interventions.

Effect of Dwell Time on the Mental Health of US Military Personnel With Multiple Combat Tours

OBJECTIVE We investigated the association of the length of time spent at home between deployments, or dwell time, with posttraumatic stress disorder (PTSD) and other mental health disorders. METHODS We included US Marine Corps personnel identified from military deployment records who deployed to Operation Iraqi Freedom once (n = 49,328) or twice (n = 16,376). New-onset mental health diagnoses from military medical databases were included. We calculated the ratio of dwell-to-deployment time (DDR) as the length of time between deployments divided by the length of the first deployment. RESULTS Marines with 2 deployments had higher rates of PTSD than did those with 1 deployment (2.1% versus 1.2%; P < .001). A DDR representing longer dwell times at home relative to first deployment length was associated with reduced odds of PTSD (odds ratio [OR] = 0.47; 95% confidence interval [CI] = 0.32, 0.70), PTSD with other mental health disorder (OR = 0.56; 95% CI = 0.33, 0.94), and other mental health disorders (OR = 0.62; 95% CI = 0.51, 0.75). CONCLUSIONS Longer dwell times may reduce postdeployment risk of PTSD and other mental health disorders. Future research should focus on the role of dwell time in adverse health outcomes.

Psychological Correlates of Battle and Nonbattle Injury Among Operation Iraqi Freedom Veterans

Limited research exists on the relationship between physical injury and PTSD within military populations. The present study assessed postinjury rates of PTSD and other psychological correlates among battle and non-battle injuries. A total of 1,968 men (831 battle injuries and 1,137 nonbattle injuries) injured between September 2004 and February 2005 during Operation Iraqi Freedom (OIF) composed the study sample. Patients were followed through November 2006 for mental health diagnosis (ICD-9 290-319). Compared with nonbattle injuries, those with battle injuries had a greater risk of PTSD and other mental health diagnosis, and there was a positive association with injury severity. Self-reported mental health symptoms were significantly higher for both minor and moderate-severe battle injury in comparison to nonbattle injury and previous population estimates from an earlier OIF period. More research is needed to further define this relationship by examining potential mechanisms and addressing the possible contributing effect of combat exposure.

Injury-specific predictors of posttraumatic stress disorder

OBJECTIVE Posttraumatic stress disorder (PTSD) is an important source of morbidity in military personnel, but its relationship with characteristics of battle injury has not been well defined. The aim of this study was to characterise the relationship between injury-related factors and PTSD among a population of battle injuries. PATIENTS AND METHODS A total of 831 American military personnel injured during combat between September 2004 and February 2005 composed the study population. Patients were followed through November 2006 for diagnosis of PTSD (ICD-9 309.81) or any mental health outcome (ICD-9 290-319). RESULTS During the follow-up period, 31.3% of patients received any type of mental health diagnosis and 17.0% received a PTSD diagnosis. Compared with minor injuries those with moderate (odds ratio [OR], 2.37; 95% confidence interval [CI], 1.61-3.48), serious (OR, 4.07; 95% CI, 2.55-6.50), and severe (OR, 5.22; 95% CI, 2.74-9.96) injuries were at greater risk of being diagnosed with any mental health outcome. Similar results were found for serious (OR, 3.03; 95% CI, 1.81-5.08) and severe (OR, 3.21; 95% CI, 1.62-6.33) injuries with PTSD diagnosis. Those with gunshot wounds were at greater risk of any mental health diagnosis, but not PTSD, in comparison with other mechanisms of injury (OR 2.07; 95% CI, 1.35, 3.19). Diastolic blood pressure measured postinjury was associated with any mental health outcome, and the effect was modified by injury severity. CONCLUSIONS Injury severity was a significant predictor of any mental health diagnosis and PTSD diagnosis. Gunshot wounds and diastolic blood pressure were significant predictors of any mental health diagnosis, but not PTSD. Further studies are needed to replicate these results and elucidate potential mechanisms for these associations.