The Joint Facial and Invasive Neck Trauma (J-FAINT) Project, Iraq and Afghanistan 2003-2011

Objective

Define the number and type of facial and penetrating neck trauma injuries sustained in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF).

Study Design

Retrospective database study.

Setting

Tertiary care level I trauma center.

Subjects and Methods

The Joint Theater Trauma Registry (JTTR) was queried for data from OIF and OEF from January 2003 to May 2011. Information on demographics; type and severity of facial, neck, and associated trauma injures; and impact on overall mortality was recorded.

Results

There were 37,523 discrete facial and penetrating neck injuries that occurred in 7177 service members. There were 25,834 soft tissue injuries and 11,689 facial fractures. The most common soft injury sites were the face/cheek (48%), neck/larynx/trachea (17%), and mouth/lip (12%). The maxilla (25%), mandible (21%), and orbit (19%) were the most common facial fracture sites. The most common mechanism of injury was penetrating (49.1%), followed by blunt (25.7%), blast (24.2%), and other/unknown/burn (1%). Injuries were associated with an overall mortality rate of 3.5%. The highest risks for mortality were treatment at a level IIa facility, female sex, prehospital intubation, and blast injury. Most injuries were mild to moderate.

Conclusion

Facial and penetrating neck trauma are common in modern warfare. Most injuries are minor to moderate and survivable. Training and potential body armor updates can be made. Medical personnel deploying to support OIF and OEF could benefit from specific training in the management of facial and penetrating neck injuries. A surgeon skilled in managing these injuries would likely be beneficial in a deployed setting.

Management of Junctional Hemorrhage in Tactical Combat Casualty Care: TCCC Guidelines?Proposed Change 13-03

The vast majority of combat casualties who die from their injuries do so prior to reaching a medical treatment facility. Although most of these deaths result from nonsurvivable injuries, efforts to mitigate combat deaths can still be directed toward primary prevention through modification of techniques, tactics, and procedures and secondary prevention through improvement and use of personal protective equipment. For deaths that result from potentially survivable injuries, mitigation efforts should be directed toward primary and secondary prevention as well as tertiary prevention through medical care with an emphasis toward prehospital care as dictated by the fact that the preponderance of casualties die in the prehospital environment. Since the majority of casualties with potentially survivable injuries died from hemorrhage, priority must be placed on interventions, procedures, and training that mitigate death from truncal, junctional, and extremity exsanguination. In response to this need, multiple novel and effective junctional tourniquets have recently been developed.

U.s. Military experience with junctional wounds in war from 2001 to 2010

BACKGROUND

In 2012, we reported on junctional wounds in war, but only of the few injuries that were critically severe.

OBJECTIVE

The purpose of the present study is to associate a wide range of junctional wounds and casualty survival over a decade in order to evidence opportunities for improvement in trauma care within a large healthcare system.

METHODS

We retrospectively surveyed data from a military trauma registry. We associated survival and injuries at the junction of the trunk and appendages in the current war (2001 to 2010).

RESULTS

The junctional injury rate rose 14-fold from 0%, its minimum in 2001, to 5%, its maximum in 2010. Of the 833 casualties with junctional injury in the study, the survival rate was 83%; its change was not statistically significant over time. Most casualties had severe extremity injuries and associated injuries of other body regions such as the face and head.

CONCLUSIONS

Junctional injury is common, severe, disabling, and lethal. The findings of this study may increase awareness of junctional injury. Opportunities for improvement which we identified included further research on the future addition of junctional codes (such as neck diagnoses) in order to align research methods to clinical care.

Endovascular management of axillo-subclavian arterial injury: a review of published experience

BACKGROUND

The role of endovascular treatment for vascular trauma, including injury to the subclavian and axillary arteries, continues to evolve. Despite growing experience with the utilization of these techniques in the setting of artherosclerotic and aneurysmal disease, published reports in traumatic subclavian and axillary arterial injuries remain confined to sporadic case reports and case series.

METHODS

We conducted a review of the medical literature from 1990 to 2012 using Pubmed and OVID Medline databases to search for all reports documenting the use of endovascular stenting for the treatment of subclavian or axillary artery injuries. Thirty-two published reports were identified. Individual manuscripts were analysed to abstract data regarding mechanism, location and type of injury, endovascular technique and endograft type utilized, follow-up, and radiographic and clinical outcomes.

RESULTS

The use of endovascular stenting for the treatment of subclavian (150) or axillary (10) artery injuries was adequately described for only 160 patients from 1996 to the present. Endovascular treatment was employed after penetrating injury (56.3%; 29 GSW; 61 SW), blunt trauma (21.3%), iatrogenic catheter-related injury (21.8%) and surgical injury (0.6%). Injuries treated included pseudoaneurysm (77), AV fistula (27), occlusion (16), transection (8), perforation (22), dissection (6), or other injuries otherwise not fully described (4). Initial endovascular stent placement was successful in 96.9% of patients. Radiographic and clinical follow-up periods ranging from hospital discharge to 70 months revealed a follow-up patency of 84.4%. No mortalities related to endovascular intervention were reported. New neurologic deficits after the use of endovascular modalities were reported in only one patient.

CONCLUSION

Endovascular treatment of traumatic subclavian and axillary artery injuries continues to evolve. Early results are promising, but experience with this modality and data on late follow-up remain limited. Additional multicenter prospective study and capture of data for these patients is warranted to further define the role of this treatment modality in the setting of trauma.

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.

Noncompressible torso hemorrhage: a review with contemporary definitions and management strategies

Trauma resulting in hemorrhage from vascular disruption within the torso is a challenging scenario, with a propensity to be lethal in the first hour following trauma. The term noncompressible torso hemorrhage (NCTH) was only recently coined as part of contemporary studies describing the epidemiology of wounding during the wars in Afghanistan and Iraq. This article provides a contemporary review of NCTH, including a unifying definition to promote future study as well as a description of resuscitative and operative management strategies to be used in this setting, and sets a course for research to improve mortality following this vexing injury pattern.

Reperfusion strategies in the management of extremity vascular injury with ischaemia

BACKGROUND

Extremity injury with ischaemia is the most common pattern of vascular trauma and is a challenge for surgeons who must make decisions about the timing and mechanism of limb reperfusion. In modern military conflicts, effective use of limb tourniquets and rapid transport of the injured have increased the number of casualties who reach a medical service with potentially survivable vascular trauma. This report provides a review of extremity ischaemia and reperfusion following vascular trauma.

METHODS

A review was undertaken of extremity vascular injury with ischaemia, including a focus on adjuncts aimed at reducing reperfusion injury and improving neuromuscular recovery and limb salvage.

RESULTS

Findings from basic and clinical research support the need to restore perfusion to an ischaemic limb as soon as possible in order to achieve optimal neuromuscular recovery. Large-animal studies demonstrate that haemorrhagic shock worsens the impact of ischaemia on the neuromuscular structures of the limb and reduces the ischaemic threshold to as little as 1 h. Surgical adjuncts such as vascular shunts, fasciotomy, regional limb cooling and ischaemic conditioning may reduce the severity of ischaemic injury. Medical therapies have also been described including hypertonic saline, statins and ethyl pyruvate, which reduce the inflammatory response following limb reperfusion.

CONCLUSION

Contemporary translational research refutes a casual approach to extremity vascular injury with ischaemia, instead emphasizing expedited reperfusion. Surgical and medical adjuncts exist to expedite reperfusion and mitigate reperfusion injury. Additional research and development of these adjuncts is necessary to improve quality or functional limb salvage after vascular trauma.

Aortic balloon occlusion is effective in controlling pelvic hemorrhage

BACKGROUND

The objective of this study was to evaluate the efficacy of resuscitative endovascular aortic balloon occlusion (REBOA) of the distal aorta in a porcine model of pelvic hemorrhage.

METHODS

Swine were entered into three phases of study: injury (iliac artery), hemorrhage (45 s), and intervention (180 min). Three groups were studied: no intervention (NI, n = 7), a kaolin-impregnated gauze (Combat Gauze) (CG, n = 7), or REBOA (n = 7). The protocol was repeated with a dilutional coagulopathy (CG-C, n = 7, and REBOA-C, n = 7). Measures of physiology, rates of hemorrhage, and mortality were recorded.

RESULTS

Rate of hemorrhage was greatest in the NI group, followed by the REBOA and CG groups (822 ± 415 mL/min versus 11 ± 13 and 0.2 ± 0.4 mL/min respectively; P < 0.001). MAP following intervention (at 15 min) was the same in the CG and REBOA groups and higher than in the NI group (70 ± 4 and 70 ± 11 mm Hg versus 5 ± 13 mm Hg respectively; P < 0.001). There was 100% mortality in the NI group, with no deaths in the CG or REBOA group. In the setting of coagulopathy, the rate of bleeding was higher in the CG-C versus the REBOA-C group (229 ± 295 mL/min versus 20 ± 7 mL/min, P = 0.085). MAP following intervention (15 min) was higher in the REBOA-C than the CG-C group (71 ± 12 mm Hg versus 28 ± 31 mm Hg; P = 0.005). There were 5 deaths (71.4%) in the CG-C group, but none in the REBOA-C group (P = 0.010).

CONCLUSION

Balloon occlusion of the aorta is an effective method to control pelvic arterial hemorrhage. This technique should be further developed as an adjunct to manage noncompressible pelvic hemorrhage.

Microvascular porcine model for the optimization of vascularized composite tissue transplantation

BACKGROUND

Devastating extremity injuries are prevalent but most often survivable on the modern battlefield. The complexity of these injuries requires advanced methods of reconstruction. This study is designed to validate the feasibility of gracilis myocutaneous flap transplantation via microvascular free tissue transfer in a porcine model. This model will facilitate study of autotransplant physiology as well as vascularized composite allotransplantation as an evolving method for reconstructing previously nonreconstructable injuries.

MATERIAL AND METHODS

A donor gracilis myocutaneous flap is procured from Yorkshire swine. The right external carotid artery and internal jugular vein are prepared as the recipient axis for microvascular anastomoses. Group 1 undergoes immediate microvascular anastomosis with resultant 1-h ischemic period. Group 2 undergoes delayed anastomosis with 3-h ischemic period. Markers of ischemia-reperfusion injury are evaluated after anastomosis and on postoperative days 1, 2, 7, and 14.

RESULTS

A novel porcine model for microvascular composite tissue transplantation is demonstrated. Ischemia period-dependent elevations in circulating biomarkers (lactate dehydrogenase [LDH], creatine kinase [CK], and aspartate transaminase [AST]) demonstrate the effects of prolonged ischemia. Both groups showed marked LDH elevation without significant statistical intergroup difference (P=0.250). The difference in CK and AST levels at 24h showed strong significance (P<0.0001).

CONCLUSIONS

A novel method of vascularized gracilis myocutaneous flap transplantation was validated in the Yorkshire swine. Assays for skeletal muscle tissue injury (LDH, CK, and AST) showed ischemia period-dependent response providing assessment of ischemia-reperfusion injury at the cellular level. Subsequent studies will evaluate agents that mitigate ischemia-reperfusion injury and transition these findings to potentiate vascularized composite allotransplantation.

Stable vesicles composed of monocarboxylic or dicarboxylic fatty acids and trimethylammonium amphiphiles

The self-assembly of cationic and anionic amphiphile mixtures into vesicles in aqueous media was studied using two different systems: (i) decanoic acid and trimethyldecylammonium bromide and (ii) hexadecanedioic acid (a simple bola-amphiphile) and trimethyldecylammonium bromide. The resulting vesicles with varying amphiphile ratios were characterized using parameters such as the critical vesicle concentration, pH sensitivity, and encapsulation efficiency. We also produced and observed giant vesicles from these mixtures using the electroformation method and confocal microscopy. The mixed catanionic vesicles were shown to be more stable than those formed by pure fatty acids. Those containing bola-amphiphile even showed the encapsulation of a small hydrophilic solute (8-hydroxypyrene-1,3,6-trisulfonic-acid), suggesting a denser packing of the amphiphiles. Compression and kinetics analysis of monolayers composed of these amphiphiles mixtures at the air/water interface suggests that the stabilization of the structures can be attributed to two main interactions between headgroups, predominantly the formation of hydrogen bonds between protonated and deprotonated acids and the additional electrostatic interactions between ammonium and acid headgroups.

Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study

OBJECTIVES

To characterize contemporary use of tranexamic acid (TXA) in combat injury and to assess the effect of its administration on total blood product use, thromboembolic complications, and mortality.

DESIGN

Retrospective observational study comparing TXA administration with no TXA in patients receiving at least 1 unit of packed red blood cells. A subgroup of patients receiving massive transfusion (≥10 units of packed red blood cells) was also examined. Univariate and multivariate regression analyses were used to identify parameters associated with survival. Kaplan-Meier life tables were used to report survival.

SETTING

A Role 3 Echelon surgical hospital in southern Afghanistan.

PATIENTS

A total of 896 consecutive admissions with combat injury, of which 293 received TXA, were identified from prospectively collected UK and US trauma registries.

MAIN OUTCOME MEASURES

Mortality at 24 hours, 48 hours, and 30 days as well as the influence of TXA administration on postoperative coagulopathy and the rate of thromboembolic complications.

RESULTS

The TXA group had lower unadjusted mortality than the no-TXA group (17.4% vs 23.9%, respectively; P = .03) despite being more severely injured (mean [SD] Injury Severity Score, 25.2 [16.6] vs 22.5 [18.5], respectively; P < .001). This benefit was greatest in the group of patients who received massive transfusion (14.4% vs 28.1%, respectively; P = .004), where TXA was also independently associated with survival (odds ratio = 7.228; 95% CI, 3.016-17.322) and less coagulopathy (P = .003).

CONCLUSIONS

The use of TXA with blood component-based resuscitation following combat injury results in improved measures of coagulopathy and survival, a benefit that is most prominent in patients requiring massive transfusion. Treatment with TXA should be implemented into clinical practice as part of a resuscitation strategy following severe wartime injury and hemorrhage.

Endovascular versus open management of blunt traumatic aortic disruption at two military trauma centers: comparison of in-hospital variables

BACKGROUND

Blunt traumatic aortic disruption (BTAD) carries significant mortality and morbidity. Traditional open repair has appreciable risks of perioperative mortality and spinal cord ischemic complications. Endovascular repair may reduce the incidence of these adverse outcomes. We present the experience at two military trauma centers with thoracic aortic endografting for trauma (TAET) and compare this with recent open experience.

METHODS

A review of inpatient records was performed. All patients undergoing open repair or TAET for acute BTAD were studied. Collected data included demographics, injury characteristics, and in-hospital variables. Descriptive statistics were calculated with two-tailed t-tests performed for comparison of continuous variables.

RESULTS

Five open and eight TAET repairs were performed. Mean age was 32 years (range 28-50) in the TAET group and 35 (25-57) in the open group. All patients, except one TAET, had at least one associated injury with thoracic injuries predominating. Twelve BTAD were just distal to the left subclavian artery. One injury, treated with TAET, was just proximal to the celiac. Operative blood loss averaged 298 +/- 394 mL in the TAET group vs. 2,400 +/- 3,800 mL in the open group (p = 0.18). Crystalloid infusions were similarly reduced in TAET patients, 1,019 +/- 532 mL vs. 4,860 +/- 1,547 mL, p < 0.05), as were red blood cell transfusions, 1.6 units vs. 5.0 units (p = 0.12). The majority of patients [6/8 (75%) TAET, 5/5 (100%) open] experienced an inpatient complication (p = 0.09). All open patients had at least one infectious complication. There were no inpatient deaths related to aortic injury or spinal cord ischemic complications.

CONCLUSIONS

TAET is feasible for the treatment of BTAD in military trauma centers. It is important for military centers to accomplish this with adequate results as endovascular technologies are now being taken to the battlefield. Decreased blood loss and resuscitation requirements compared to open repair are likely contributors to improved outcomes with TAET.