Frank K. Butler

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

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

Eliminating Preventable Death on the Battlefield

OBJECTIVE To evaluate battlefield survival in a novel command-directed casualty response system that comprehensively integrates Tactical Combat Casualty Care guidelines and a prehospital trauma registry. DESIGN Analysis of battle injury data collected during combat deployments. SETTING Afghanistan and Iraq from October 1, 2001, through March 31, 2010. PATIENTS Casualties from the 75th Ranger Regiment, US Army Special Operations Command. MAIN OUTCOME MEASURES Casualties were scrutinized for preventable adverse outcomes and opportunities to improve care. Comparisons were made with Department of Defense casualty data for the military as a whole. RESULTS A total of 419 battle injury casualties were incurred during 7 years of continuous combat in Iraq and 8.5 years in Afghanistan. Despite higher casualty severity indicated by return-to-duty rates, the regiments rates of 10.7% killed in action and 1.7% who died of wounds were lower than the Department of Defense rates of 16.4% and 5.8%, respectively, for the larger US military population (P = .04 and P = .02, respectively). Of 32 fatalities incurred by the regiment, none died of wounds from infection, none were potentially survivable through additional prehospital medical intervention, and 1 was potentially survivable in the hospital setting. Substantial prehospital care was provided by nonmedical personnel. CONCLUSIONS A command-directed casualty response system that trains all personnel in Tactical Combat Casualty Care and receives continuous feedback from prehospital trauma registry data facilitated Tactical Combat Casualty Care performance improvements centered on clinical outcomes that resulted in unprecedented reduction of killed-in-action deaths, casualties who died of wounds, and preventable combat death. This data-driven approach is the model for improving prehospital trauma care and casualty outcomes on the battlefield and has considerable implications for civilian trauma systems.

Battlefield trauma care then and now: a decade of Tactical Combat Casualty Care.

Abstract : Maughon reported in 1970 that 193 of a cohort of 2,600 casualties that were killed in action in Vietnam died of isolated extremity hemorrhage. The percentage of fatalities that resulted from exsanguination from extremity wounds was 7.9%; this was the leading cause of preventable death among US military casualties in the Vietnam War. Maughon commented at the time that little progress had been made in battlefield trauma care in the last 100 years. A sobering postscript to Maughon s observations in 1970 is found in the preventable death analyses done by Holcomb et al.2 and Kelly et al.3 in the current conflicts. Holcomb et al. found a 15% incidence of potentially preventable fatalities in his article that reviewed all Special Operations deaths in Iraq and Afghanistan from the initiation of hostilities until November 2004. He found that 25% (3 of 12) fatalities with potentially survivable injuries might have been saved by the simple application of a tourniquet. The larger causes of death analysis by Kelly et al. studied 982 fatalities from the first 5 years of the conflicts in Afghanistan and Iraq. He documented that 77 of 232 potentially preventable deaths from the Armed Forces Medical Examiner records resulted from failure to use a tourniquet; exsanguination from isolated extremity wounds thus caused 7.8% of the combat-related deaths reported in the article of Kelly et al.. The failure to make progress in addressing the leading cause of preventable deaths on the battlefield in the 30 years between the Vietnam and Afghanistan wars, despite the ready availability of the requisite technology, dramatically underscores Maughon s point about the lack of progress in battlefield trauma care.

An Evidence-based Prehospital Guideline for External Hemorrhage Control: American College of Surgeons Committee on Trauma

Abstract This report describes the development of an evidence-based guideline for external hemorrhage control in the prehospital setting. This project included a systematic review of the literature regarding the use of tourniquets and hemostatic agents for management of life-threatening extremity and junctional hemorrhage. Using the GRADE methodology to define the key clinical questions, an expert panel then reviewed the results of the literature review, established the quality of the evidence and made recommendations for EMS care. A clinical care guideline is proposed for adoption by EMS systems. Key words: tourniquet; hemostatic agents; external hemorrhage

Tranexamic Acid and Trauma: Current Status and Knowledge Gaps with Recommended Research Priorities

ABSTRACT A recent large civilian randomized controlled trial on the use of tranexamic acid (TXA) for trauma reported important survival benefits. Subsequently, successful use of TXA for combat casualties in Afghanistan was also reported. As a result of these promising studies, there has been growing interest in the use of TXA for trauma. Potential adverse effects of TXA have also been reported. A US Department of Defense committee conducted a review and assessment of knowledge gaps and research requirements regarding the use of TXA for the treatment of casualties that have experienced traumatic hemorrhage. We present identified knowledge gaps and associated research priorities. We believe that important knowledge gaps exist and that a targeted, prioritized research effort will contribute to the refinement of practice guidelines over time.

Tactical Combat Casualty Care: update 2009.

COMMITTEE ON TACTICAL COMBAT CASUALTY CARE The Committee on Tactical Combat Casualty Care (CoTCCC) was begun in 2001 as a US Special Operations Command biomedical research project. It was first established at the Naval Operational Medicine Institute and was supported by the Navy Bureau of Medicine and Surgery from fiscal year (FY) 2004 through FY 2009. In FYs 2007–2009, the Office of the Surgeon General of the Army and the US Army Institute of Surgical Research (USAISR) also helped to fund the activities of the CoTCCC. In 2007, because of the increasing visibility of TCCC in the conflicts in Iraq and Afghanistan, the Navy Medical Support Command proposed that the CoTCCC be considered for realignment at a more senior joint command. The CoTCCC was subsequently realigned to function as a subgroup of the Trauma and Injury Subcommittee of the Defense Health Board (DHB). The DHB is the senior external medical advisory group to the Secretary of Defense.

Trauma hemostasis and oxygenation research position paper on remote damage control resuscitation: definitions, current practice, and knowledge gaps.

ABSTRACT The Trauma Hemostasis and Oxygenation Research Network held its third annual Remote Damage Control Resuscitation Symposium in June 2013 in Bergen, Norway. The Trauma Hemostasis and Oxygenation Research Network is a multidisciplinary group of investigators with a common interest in improving outcomes and safety in patients with severe traumatic injury. The network’s mission is to reduce the risk of morbidity and mortality from traumatic hemorrhagic shock, in the prehospital phase of resuscitation through research, education, and training. The concept of remote damage control resuscitation is in its infancy, and there is a significant amount of work that needs to be done to improve outcomes for patients with life-threatening bleeding secondary to injury. The prehospital phase of resuscitation is critical in these patients. If shock and coagulopathy can be rapidly identified and minimized before hospital admission, this will very likely reduce morbidity and mortality. This position statement begins to standardize the terms used, provides an acceptable range of therapeutic options, and identifies the major knowledge gaps in the field.

Improving survival from active shooter events: The hartford consensus

T recent mass casualty shooting events in the United States have had a profound effect on all segments of society. The medical, law enforcement, fire/rescue, and EMS communities have each felt the need to respond. It is important that these efforts occur in a coordinated manner to generate policies that will enhance survival of the victims of these events. Such policies must provide a synchronized multi-agency approach that is immediately available within the communities affected by such tragedies. The American College of Surgeons brought together senior leaders from all the aforementioned disciplines to produce a document that will stimulate discussion and ultimately lead to strategies to improve survival for the victims. A day-long conference on April 2, 2013, in Hartford, Connecticut obtained input from medical, law enforcement, fire/rescue, EMS first responders, and military experts. The conference relied upon data and evidence from existing military and recent civilian experiences, and was sensitive to the multiple agencies that play a role in responding to mass casualty shootings. The meeting, known as the Hartford Consensus Conference, produced a concept paper entitled ‘‘Improving Survival from Active Shooter Events.’’ The purpose of this document is to promote local, state, and national policies to improve survival in these uncommon, but horrific events. The following short essay describes methods to minimize loss of life in these terrible incidents.

Prehospital Interventions Performed in a Combat Zone: A Prospective Multicenter Study of 1,003 Combat Wounded

BACKGROUND Battlefield care given to a casualty before hospital arrival impacts clinical outcomes. To date, the published data regarding care given in the prehospital setting of a combat zone are limited. The purpose of this study was to describe the incidence and efficacy of specific prehospital lifesaving interventions (LSIs; interventions that could affect the outcome of the casualty), consistent with the Tactical Combat Casualty Care paradigm, performed during the resuscitation of casualties in a combat zone. METHODS We performed a prospective observational study between November 2009 and November 2011. Casualties were enrolled as they were treated at six US surgical facilities in Afghanistan. Descriptive data were collected on a standardized data collection form and included mechanism of injury, airway management, chest and hemorrhage interventions, vascular access, type of fluid administered, and hypothermia prevention. On arrival to the military hospital, the treating physician determined whether an intervention was performed correctly and whether an intervention was not performed that should have been performed (missed LSI). RESULTS A total of 1,003 patients met the inclusion criteria. Their mean (SD) age was 25 (8.5) years and 97% were male. The mechanism of injury was explosion in 60% of patients, penetrating in 24% of patients, blunt in 15% of patients, and burn in 0.8% of patients. The most commonly performed LSIs included hemorrhage control (n = 599), hypothermia prevention (n = 429), and vascular access (n = 388). Of the missed LSIs, 252 were identified with the highest percentage of missed opportunities being composed of endotracheal intubation, chest needle decompression, and hypotensive resuscitation. In contrast, tourniquet application had the lowest percentage of missed opportunities. CONCLUSIONS In our prospective study of prehospital LSIs performed in a combat zone, we observed a higher rate of incorrectly performed and missed LSIs in airway and chest (breathing) interventions than hemorrhage control interventions. The most commonly performed LSIs had lower incorrect and missed LSI rates. LEVEL OF EVIDENCE Prognostic study, level III.

State of the Art of Fluid Resuscitation 2010: Prehospital and Immediate Transition to the Hospital

Abstract : The Prehospital Fluid Conference was sponsored by the US Army Institute of Surgical Research and Combat Casualty Care Research, US Army Medical Research and Materiel Command. Some 65 conferees were invited in January 2010 to review the contemporary guidelines on the use of fluid resuscitation in treating combat casualties, discuss the state of the art of fluid resuscitation for combat casualties, and answer the following questions: - Are current Tactical Combat Casualty Care (TCCC) intravenous (IV) fluid resuscitation guidelines optimal for today? - Which IV fluid should be the top priority for future research? - What are the current indications for fluid resuscitation in the combat trauma patient? - What is the current practice in tactical fluid resuscitation? The objective of this conference was to identify the fluid to be used by the prehospital provider and not to address the needs once definitive hemorrhage control has been achieved. The fluids to be used are those that will be carried into the field on the back of the combat medic or in the vehicle used to transport the medic or the patient (echelon 1 care). There are several definitions of these echelons of care (North Atlantic Treaty Organization [NATO], European forces, etc.). The definitions used in this document are those of the Joint Theater Trauma System. The use of role and echelon can be interchangeable depending on the country of origin, but the terms can vary significantly. Echelon, as used in many/most of Joint Theater Trauma System presentations will be used throughout this document to indicate a level of care facility (see Table 1). Although discussions focused on military needs, it was understood and accepted by the consensus group that many, if not all, of the recommendations could and would be used for civilian prehospital providers with appropriate situational modifications.