Trauma System Development in a Theater of War: Experiences From Operation Iraqi Freedom and Operation Enduring Freedom

Emergent interfacility evacuation of critical care patients in combat

During the Second Iraq War (Operation Iraqi Freedom), high-intensity, low-utilization medical and surgical services, such as neurosurgical care, were consolidated into a centralized location within the combat zone. This arrangement necessitated intra-theater air medical evacuation of critically ill or injured patients from outlying combat support hospitals (CSH) to another combat zone facility having the needed services. A case series is presented of intratheater transfer of neurosurgical patients in Iraq during 2005-06. Ninety-eight patients are included in the series, with typical transfer distances of 40 miles (approximately 20-25 minutes of flight time). All patients were transported with a CSH nurse in addition to the standard Army EMT-B flight medic. Seventy-six percent of cases were battle injury, 17% were non-battle injuries, and the balance were classified as non-injury mechanisms. Seventy-six percent of cases were head injuries, with the balance involving burns, stroke, and other injuries. At 30 days, 12% of the patients had died, and 9% remained hospitalized in a critical care setting. None of the patients died during evacuation. Intratheater and interfacility transfer of critical care patients in the combat theater often involves severely head-injured and other neurosurgical cases. Current Army staffing for helicopter transport in these case requires a nurse or other advanced personnel to supplement the standard EMT-B flight medic.

Hypothermia in trauma

Hypovolaemic shock that results through traumatically inflicted haemorrhage can have disastrous consequences for the victim. Initially the body can compensate for lost circulating volume, but as haemorrhage continues compensatory mechanisms fail and the patient's condition worsens significantly. Hypovolaemia results in the lethal triad, a combination of hypothermia, acidosis and coagulopathy, three factors that are interlinked and serve to worsen each other. The lethal triad is a form of vicious cycle, which unless broken will result in death. This report will focus on the role of hypothermia (a third of the lethal triad) in trauma, examining literature to assess how prehospital temperature control can impact on the trauma patient. Spontaneous hypothermia following trauma has severely deleterious consequences for the trauma victim; however, both active warming of patients and clinically induced hypothermia can produce particularly positive results and improve patient outcome. Possible coagulopathic side effects of clinically induced hypothermia may be corrected with topical haemostatic agents, with the benefits of an extended golden hour given by clinically induced hypothermia far outweighing these risks. Active warming of patients, to prevent spontaneous trauma induced hypothermia, is currently the only viable method currently available to improve patient outcome. This method is easy to implement requiring simple protocols and contributes significantly to interrupting the lethal triad. However, the future of trauma care appears to lie with clinically induced therapeutic hypothermia. This new treatment provides optimism that in the future the number of deaths resulting from catastrophic haemorrhaging may be significantly lessened.

The effects of prehospital plasma on patients with injury: a prehospital plasma resuscitation

BACKGROUND

The prehospital resuscitation of the exsanguinating patient with trauma is time and resource dependent. Rural trauma care magnifies these factors because transportation time to definitive care is increased. To address the early resuscitation needs and trauma-induced coagulopathy in the exsanguinating patient with trauma an aeromedical prehospital thawed plasma-first transfusion protocol was used.

METHODS

Retrospective review of trauma and flight registries between February 1, 2009, and May 31, 2011, was performed. The study population included all patients with traumatic injury transported by rotary wing aircraft who met criteria for massive transfusion protocol

RESULTS

A total of 59 patients identified over 28 months met criteria for initiation of aeromedical initiation of prehospital blood product resuscitation. Nine patients received thawed plasma-first protocol compared with 50 controls. The prehospital plasma group was more commonly on warfarin (22 vs. 2%, p = 0.036) and had a greater degree of coagulopathy measured by international normalized ratio at baseline (2.6 vs. 1.5, p = 0.004) and trauma center arrival (1.6 vs. 1.3, p < 0.001). The prehospital plasma group had a predicted mortality nearly three times greater than controls based on Trauma and Injury Severity Score (0.24 vs. 0.66, p = 0.005). The use of prehospital plasma resuscitation led to a plasma-red blood cell ratio that more closely approximated a 1:1 resuscitation en route (1.3:1.0 vs. not applicable, p < 0.001), at 30 minutes (1.3:1.0 vs. 0.14:1.0, p < 0.001), at 6 hours (0.95:1.0 vs. 0.42:1.0, p < 0.001), and at 24 hours (1.0:1.0 vs. 0.45:1.0, p < 0.001). An equivalent amount of packed red blood cells were transfused between the groups. Despite more significant hypotension, less crystalloid was used in the prehospital thawed plasma group, through 24 hours after injury (6.3 vs. 16.4 L, p = 0.001).

CONCLUSION

Use of plasma-first resuscitation in the helicopter system creates a field ready, mobile blood bank, allowing early resuscitation of the patient demonstrating need for massive transfusion. There was early treatment of trauma-induced coagulopathy. Although there was not a survival benefit demonstrated, there was resultant damage control resuscitation extending to 24 hours in the plasma-first cohort.

Invasive mold infections following combat-related injuries

BACKGROUND

Major advances in combat casualty care have led to increased survival of patients with complex extremity trauma. Invasive fungal wound infections (IFIs) are an uncommon, but increasingly recognized, complication following trauma that require greater understanding of risk factors and clinical findings to reduce morbidity.

METHODS

The patient population includes US military personnel injured during combat from June 2009 through December 2010. Case definition required wound necrosis on successive debridements with IFI evidence by histopathology and/or microbiology (Candida spp excluded). Case finding and data collected through the Trauma Infectious Disease Outcomes Study utilized trauma registry, hospital records or operative reports, and pathologist review of histopathology specimens.

RESULTS

A total of 37 cases were identified: proven (angioinvasion, n=20), probable (nonvascular tissue invasion, n=4), and possible (positive fungal culture without histopathological evidence, n=13). In the last quarter surveyed, rates reached 3.5% of trauma admissions. Common findings include blast injury (100%) during foot patrol (92%) occurring in southern Afghanistan (94%) with lower extremity amputation (80%) and large volume blood transfusion (97.2%). Mold isolates were recovered in 83% of cases (order Mucorales, n=16; Aspergillus spp, n=16; Fusarium spp, n=9), commonly with multiple mold species among infected wounds (28%). Clinical outcomes included 3 related deaths (8.1%), frequent debridements (median, 11 cases), and amputation revisions (58%).

CONCLUSIONS

IFIs are an emerging trauma-related infection leading to significant morbidity. Early identification, using common characteristics of patient injury profile and tissue-based diagnosis, should be accompanied by aggressive surgical and antifungal therapy (liposomal amphotericin B and a broad-spectrum triazole pending mycology results) among patients with suspicious wounds.

Hypothermia in trauma patients: predicting the big chill

Physicians commonly ignore hypothermia, an often-underappreciated event associated with mortality in trauma patients, in general due to its prevalence and belief that it is secondary to the injury itself (secondary hypothermia). Over the past several decades, hypothermia in trauma has been studied concerning its effects on mortality; however, very little has been done to identify the major risk factors associated with it. The study by Lapostolle and colleagues has attempted to incorporate environmental risk factors and prehospital care along with more traditional variables for the prediction of hypothermia at admission.

Defining and predicting surgeon utilization at forward surgical teams in Afghanistan

BACKGROUND

The forward surgical team (FST) is the US Army's smallest surgical element. These teams have supported current conflicts since 2001. The purpose of this study was to determine if surgeon utilization varied at two different FSTs and to determine factors that may predict the need for a surgeon.

METHOD

Data from two FSTs were reviewed. A t-test was used to compare the military injury severity scores (mISS) and the revised trauma scores (RTS). χ(2) analysis was used to compare types and mechanisms of injury and to compare life- or limb-saving surgeries (LLSS) and life-saving interventions among the FSTs. Logistic regression was used to determine if mISS, RTS, physiologic parameters, or laboratory values predicted the need for LLSS or life-saving intervention.

RESULTS

The 541st FST treated a larger volume of patients than the 772nd FST (n = 761 versus n = 311). The 772nd FST performed a significantly higher percentage of LLSS; however, absolute number of LLSS was 31 at both FSTs. The mISS among operative patients were similar, but RTS were significantly different (772nd FST = 7.28 versus 541st FST = 7.58, P = 0.008). The 772nd FST saw a higher percentage of motor vehicle collision and rocket-propelled grenade injuries and thoracic and neurologic injuries, and the 541st FST saw a higher percentage of blast and gunshot wound injuries and abdominal injuries. Lactate level was the most significant predictor of the need for LLSS.

CONCLUSION

Although percentage of surgical interventions varied between the two FSTs, the absolute number of needed surgical interventions was the same and was small. Lactate level predicted the need for surgical intervention in our population.

Transfusion medicine in trauma patients: an update

In 2008, we reviewed the practical interface between transfusion medicine and the surgery and critical care of severely injured patients. Reviewed topics ranged from epidemiology of trauma to patterns of resuscitation to the problems of transfusion reactions. In the interim, trauma specialists have adopted damage control resuscitation and become much more knowledgeable and thoughtful about the use of blood products. This new understanding and the resulting changes in clinical practice have raised new concerns. In this update, we focus on which patients need damage control resuscitation, current views on the optimal form of damage control resuscitation with blood products, the roles of newer blood products, and appropriate transfusion triggers in the postinjury setting. We will also review the role of new technology in patient assessment, therapy and monitoring.

The Canadian Forces trauma care system

According to the Trauma Association of Canada, a trauma system is a preplanned, organized and coordinated injury-control effort in a defined geographic area. An effective trauma system engages in comprehensive injury surveillance and prevention programs; delivers trauma care from the time of injury to recovery; engages in research, training and performance improvement; and establishes linkages with an all-hazards emergency preparedness program. To support Canada's combat mission in Afghanistan, the Canadian Forces (CF) developed a comprehensive trauma system based around its trauma hospital--the Role 3 Multinational Medical Unit (R3MMU) at Kandahar Airfield. This article reviews the essential components of a modern trauma system, outlines the evidence that trauma systems improve care to injury victims and describes how the current CF trauma system was developed.

Impact of improved combat casualty care on combat wounded undergoing exploratory laparotomy and massive transfusion

BACKGROUND

Studies have shown decreased mortality after improvements in combat casualty care, including increased fresh frozen plasma (FFP):red blood cell (RBC) ratios. The objective was to evaluate the evolution and impact of improved combat casualty care at different time periods of combat operations.

METHODS

A retrospective review was performed at one combat support hospital in Iraq of patients requiring both massive transfusion (≥ 10 units RBC in 24 hours) and exploratory laparotomy. Patients were divided into two cohorts based on year wounded: C1 between December 2003 and June 2004, and C2 between September 2007 and May 2008. Admission data, amount of blood products and fluid transfused, and 48 hour mortality were compared. Statistical significance was set at p < 0.05.

RESULTS

There was decreased mortality in C2 (47% vs. 20%). Patients arrived warmer with higher hemoglobin. They were transfused more RBC and FFP in the emergency department (5 units ± 3 units vs. 2 units ± 2 units; 3 units ± 2 units vs. 0 units ± 1 units, respectively) and received less crystalloid in operating room (3.3 L ± 2.2 L vs. 8.5 L ± 4.9 L). The FFP:RBC ratio was also closer to 1:1 in C2 (0.775 ± 0.32 vs. 0.511 ± 0.21).

CONCLUSIONS

The combination of improved prehospital care, trauma systems approach, performance improvement projects, and improved transfusion or resuscitation practices have led to a 50% decrease in mortality for this critically injured population. We are now transfusing blood products in a ratio more consistent with 1 FFP to 1 RBC. Simultaneously, crystalloid use has decreased by 61%, all of which is consistent with hemostatic resuscitation principles.

Mechanism of injury affects acute coagulopathy of trauma in combat casualties

BACKGROUND

Recent evidence suggests trauma involving total body tissue damage increases the acute coagulopathy of trauma (ACOT) by various mechanisms, especially in massive transfusion (MT). Our hypothesis was that MT patients injured by explosion will have a higher international normalization ratio (INR) at admission than MT patients injured by gunshot wound (GSW).

METHODS

A retrospective review was performed on US military injured in Operation Iraqi Freedom/Operation Enduring Freedom from March 2003 to September 2008, who received MT (≥ 10 red blood cells in 24 hours) and had an INR on admission. Two cohorts were created based on mechanism. Admission vital signs, labs, transfusion, and mortality data were compared.

RESULTS

Seven hundred fifty-one MT patients were identified. Four hundred fifty patients had admission INR and were injured by either GSW or explosion. Patients demonstrated similar injury severity scale and Glasgow Coma Scale. Patients injured by explosion presented with higher INR, greater base deficit, and more tachycardic than patients injured by GSW. Transfusion of blood products was similar between both groups.

CONCLUSIONS

The primary finding of this study is that patients injured by explosion presented with a higher INR than those injured by GSW, even with similar injury severity scale. In addition, patients injured by explosion presented more tachycardic and with a greater base deficit. These findings support the theory that ACOT is affected by the amount of tissue injured. Further research is needed into the pathophysiology of ACOT because this may impact care of patients with total body tissue damage/hypoxia and improve the treatment of their coagulopathy while minimizing the attendant complications.

Antimicrobial prescribing practices following publication of guidelines for the prevention of infections associated with combat-related injuries

BACKGROUND

Timely and limited antibiotic prophylaxis (postinjury antimicrobial therapy) targeting specific traumatic injuries is a well-recognized measure to lessen posttraumatic infection. Modern military combat injuries raise significant challenges because of complex multiple injuries and limited data derived directly from well-controlled trials to base recommendations. Expert consensus review of available evidence led to published guidance for selection and duration of antimicrobial therapy for combat-related trauma infection prevention. This analysis evaluates antibiotic-prescribing practices by military physicians in the operational theater relative to the published guidance.

METHODS

Trauma history and infectious disease-specific inpatient care information is captured through the Joint Theater Trauma Registry along with a supplemental infectious disease module. Injury patterns are classified based on documented International Classification of Diseases-9th Revision codes with a composite assessment of each patient's injury pattern. Antimicrobial use categorized as prophylaxis is prescribed within the first 48 hours postinjury. Adherence to published guidance is reported along with patient characteristics and injury severity to assess for potential explanations of nonadherence.

RESULTS

During June to November 2009, 75% of the 610 eligible trauma patients received antimicrobial prophylaxis. Adherence to the recommended antibiotic agent on the day of injury was in the range of 46% to 50% for the most common extremity injury patterns and <10% in penetrating abdominal injuries. Antibiotics were given in 39% of patients sustaining injuries that are recommendations to not receive antimicrobial prophylaxis.

CONCLUSIONS

This first evaluation of combat trauma-related antibiotic prophylaxis shows adherence levels comparable or superior to reported rates in civilian settings despite the austere, frequently mass casualty environment. Areas for interval surveillance and education-based strategies for improved adherence to practice guidance are identified.

A model to advance nursing science in trauma practice and injury outcomes research

AIMS

This discussion paper reports development of a model to advance nursing science and practice in trauma care based on an analysis of the literature and expert opinion.

BACKGROUND

The continuum of clinical care provided to trauma patients extends from the time of injury through to long-term recovery and final outcomes. Nurses bring a unique expertise to meet the complex physical and psychosocial needs of trauma patients and their families to influence outcomes across this entire continuum.

DATA SOURCES

Literature was obtained by searching CINAHL, PubMed and OvidMedline databases for 1990-2010. Search terms included trauma, nursing, scope of practice and role, with results restricted to those published in English. Manual searches of relevant journals and websites were undertaken.

DISCUSSION

Core concepts in this trauma outcomes model include environment, person/family, structured care settings, long-term outcomes and nursing interventions. The relationships between each of these concepts extend across all phases of care. Intermediate outcomes are achieved in each phase of care and influence and have congruence with long-term outcomes. Implications for policy and practice.  This model is intended to provide a framework to assist trauma nurses and researchers to consider the injured person in the context of the social, economic, cultural and physical environment from which they come and the long-term goals that each person has during recovery. The entire model requires testing in research and assessment of its practical contribution to practice.

CONCLUSION

Planning and integrating care across the trauma continuum and recognition of the role of the injured person's background, family and resources will lead to improved long-term outcomes.

Evolution of the Literature Identifying Physicians' Roles in Leadership, Clinical Development, and Practice of the Subspecialty of Emergency Medical Services

Purpose: The 2007 Institute of Medicine report entitled Emergency Medical Services at the Crossroads identified a need for the establishment of physician subspecialty certification in emergency medical services (EMS). The purpose of this study was to identify and explore the evolution of publications that define the role of the physician in EMS systems in the United States.

Methods: Three comprehensive searches were undertaken to identify articles that define the physician's role in the leadership, clinical development, and practice of EMS. Independent reviewers then evaluated these articles to further determine whether the articles identified the physician's role in EMS. Then, identified articles were classified by the type of publication in order to evaluate the transition from a non-peer reviewed to peer-reviewed literature base and an analysis was performed on the differences in the growth between these two groups. In addition, for the peer-reviewed articles, an analysis was performed to identify the proportion of articles that were quantitative versus qualitative in nature.

Results: The comprehensive review identified 1,504 articles. Ninety articles were excluded due to lack of relevance to the US. The remaining 1,414 articles were reviewed, and 194 papers that address the physician's role within EMS systems were identified; 72 additional articles were identified by hand search of references for a total of 266 articles. The percentage of peer-reviewed articles has increased steadily over the past three decades. In addition, the percentage of quantitative articles increased from the first decade to the second and third decades.

Conclusions: This comprehensive review demonstrates that over the past 30 years an evidence base addressing the role of the physician in EMS has developed. This evidence base has steadily evolved to include a greater proportion of peer-reviewed, quantitative literature.

Advancing critical care: joint combat casualty research team and joint theater trauma system

Despite the severity and complexity of injuries, survival rates among combat casualties are equal to or better than those from civilian trauma. This article summarizes the evidence regarding innovations from the battlefield that contribute to these extraordinary survival rates, including preventing hemorrhage with the use of tourniquets and hemostatic dressings, damage control resuscitation, and the rapid evacuation of casualties via MEDEVAC and the US Air Force Critical Care Air Transport Teams. Care in the air for critically injured casualties with pulmonary injuries and traumatic brain injury is discussed to demonstrate the unique considerations required to ensure safe en route care. Innovations being studied to decrease sequelae associated with complex orthopedic and extremity trauma are also presented. The role and contributions of the Joint Combat Casualty Research Team and the Joint Theater Trauma System are also discussed.

Transfusion-transmissible viral infections among US military recipients of whole blood and platelets during Operation Enduring Freedom and Operation Iraqi Freedom

BACKGROUND

Current US military clinical practice guidelines permit emergency transfusions of non-Food and Drug Administration (FDA)-compliant freshly collected blood products in theaters of war. This investigation aimed to characterize the risks of transfusion-transmitted infections (TTIs) associated with battlefield transfusions of non-FDA-compliant blood products.

STUDY DESIGN AND METHODS

US Service members who received emergency transfusion products in Iraq and Afghanistan (March 1, 2002-September 30, 2007) were tested for hepatitis C virus (HCV), human immunodeficiency virus (HIV), and hepatitis B virus (HBV) infections using reposed pre- and posttransfusion sera. Selected regions of viral genomes from epidemiologically linked infected recipients and their donors were sequenced and compared.

RESULTS

Of 761 US Service members who received emergency transfusion products, 475 were tested for HCV, 472 for HIV, and 469 for HBV. One transfusion-transmitted HCV infection (incidence rate of 2.1/1000 persons) was identified. The pretransfusion numbers (prevalence per 1000 persons) were HCV-four (8/1000), HIV-zero (0/1000), chronic HBV-two (4 /1000), and naturally immune (antibody to HBV core antigen)-nine (19/1000).

CONCLUSION

One HCV TTI was determined to be associated with emergency blood product use. The pretransfusion HCV and HBV prevalence in transfusion recipients, themselves members of the potential donor population, indicates better characterization of the deployed force's actual donor population, and further investigations of the TTI prevalence in these donors are needed. These data will inform countermeasure development and clinical decision making.

Impact of policy change on US Army combat transfusion practices

BACKGROUND

Clinical practice guidelines (CPGs) are used to keep providers up-to-date with the most recent literature and to guide in decision making. Adherence is typically improved although many have a muted impact. In March 2006, the US Army issued a damage control resuscitation CPG, encouraging 1:1 plasma:red blood cell (RBC) transfusions and limiting crystalloid use. The objective of this study was to determine whether the CPG was associated with a change in the transfusion practices in combat-wounded patients.

METHODS

All US service members injured in Operation Iraqi Freedom/Operation Enduring Freedom who received massive transfusions (MTs; > or = 10 RBC in 24 hours) were queried from the US Army Institute of Surgical Research transfusion database. Whole blood, when used, was counted as 1 unit of RBC, fresh frozen plasma (FFP), and platelet. Subjects were divided into pre- and post-CPG cohorts. Primary outcomes were ratios of FFP:RBC and crystalloid use.

RESULTS

A total of 777 MT patients were identified. The cohorts were similar in age (25 years +/- 6 years vs. 25 years +/- 6 years; p = ns) and injury severity scale score (24 +/- 12 vs. 25 +/- 12; p = ns). The post-CPG cohort was warmer (96.5 degrees F +/- 7.8 degrees F vs. 98.2 degrees F +/- 1.9 degrees F; p < 0.05) and was transfused more RBC, platelets, and plasma but received less crystalloid (17 units +/- 12 units vs. 19 units +/- 11 units, 1 unit +/- 2 units vs. 2 units +/- 3 units, 8 units +/- 8 units vs. 14 units +/- 11 units, 14 L +/- 14 L vs. 9 L +/- 13 L, respectively; p < 0.05). The post-CPG cohort also received a higher ratio transfusion (0.5 +/- 0.31 vs. 0.8 +/- 0.31; p < 0.05) representing a change in practice. Overall mortality was not different between the two groups (24 vs. 19%; p = 0.115).

CONCLUSIONS

MT patients are now receiving a higher FFP:RBC ratio and less crystalloid after implementation of the CPG. Additionally, patients are now presenting normothermic and have higher hemoglobin levels. All of these changes are consistent with the principles of damage control resuscitation. Changes in practice were associated with implementation of the CPG, maturity of the battlefield, and increased availability of products.

Combat surgeons before, during, and after war: the legacy of Loyal Davis

By 1942, Loyal Davis had firmly established himself as a preeminent civilian neurosurgeon. With military operations rapidly escalating, he was recruited to serve in the European Theater of Operations as a consultant to the Surgeon General. Davis brought tremendous experience, insight, and leadership to this position; however, he found the military system in which he was suddenly immersed inefficient and impassive. His requests for even basic equipment became mired in endless bureaucracy even as his communiqués to the Chief Surgeon in the European Theater and to the Surgeon General's staff in Washington seemed to fall short of their intended recipients. Then, when he attempted to vent his frustrations to his academic colleagues, he was nearly court-martialed. Notwithstanding, Davis became the first to formally recognize high-altitude frostbite and also developed protective headgear for airmen, and later in his service, he joined a contingent of senior medical leaders who visited the Soviet Union to study their system of combat casualty care. Subsequent to his service on active duty, Davis returned to his academic practice at Northwestern where he used his position as editor of Surgery, Gynecology, and Obstetrics to advocate for change within the military medical corps. Others like Davis have contributed greatly to the advancement of combat casualty care both during active service and long after their time in uniform. This paper examines the lessons from Davis's experiences as a military neurosurgeon and his continued advocacy for change in the medical corps along with additional recent examples of change effected by former military surgeons. For those currently serving, these lessons illustrate the value of contributing wherever a need is recognized, and for those who have served in the past, they demonstrate the importance of having a continued voice with junior combat surgeons and the military leadership.

An upshot of war - damage control resuscitation

Management of battlefield casualties in Iraq and Afghanistan has seen considerable development in damage control resuscitation, which aims to address the risk of haemorrhage, initially due to mechanical damage; and thereafter due to the development of life-threatening coagulopathy. Damage control resuscitation combines a variety of techniques, such as the use of the combat application tourniquet and novel haemostatics, through to ground-breaking developments in transfusion protocols. These practical aspects of the doctrine are combined with an ethos which sees consultant-led care implemented from as close to the point of wounding as is possible. Meticulous trauma audit is included in this process and has allowed for rapid translation of knowledge into practice. The main elements of this doctrine are described.

Impact of hypothermia in the rural, pediatric trauma patient

OBJECTIVE

Hypothermia is an independent predictor of mortality in adult trauma studies. However, the impact of hypothermia on the pediatric trauma population has not been described. The purpose of this study is to evaluate hypothermia as a cofactor to mortality, complications, and among survivors, hospital length of stay parameters in the pediatric trauma population.

DESIGN

Retrospective review of a prospectively collected database (National Trauma Registry of the American College of Surgeons) over a 5-yr period (July 2002 to June 2007).

SETTING

A rural, level I trauma center.

PATIENTS

One thousand six hundred twenty-nine pediatric patients admitted with a traumatic injury.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Multivariate regression models were used to evaluate the association of hypothermia with mortality, infectious complications, organ dysfunction, and among survivors, hospital length of stay parameters. Of 1,629 pediatric trauma patients admitted, 182 (11.1%) patients were hypothermic (temperature below 36 degrees C) on admission. Hypothermia had an adjusted odds ratio (AOR) of 2.41 (95% confidence interval [CI], 1.12-5.22, p = .025) for mortality. After controlling for covariates, hypothermia had associations with developing pneumonia (AOR, 0.185, 95% CI, 0.040-0.853; p = .031) and a bleeding diathesis (AOR, 3.14, 95% CI, 1.04-9.44; p = .042). The median days in the hospital, intensive care unit (ICU), and ventilator were longer in the hypothermic cohort; however, after controlling for covariates, hypothermia was not associated with differences in hospital days, ICU days, or ventilator days.

CONCLUSIONS

Hypothermia is a common problem at admission among pediatric trauma patients. Hypothermia is associated with an increase in the odds of death and the development of a bleeding diathesis, while having decreased odds for developing pneumonia. While the length of stay indicators were longer in the hypothermic cohort among survivors, no significant association was noted with hypothermia for hospital, ICU, or ventilator days after controlling for confounders.

Transfusion therapy in hemorrhagic shock

PURPOSE OF REVIEW

Bleeding and death from hemorrhage remain a leading cause of morbidity and mortality in the trauma population. Early resuscitation of these gravely injured patients has changed significantly over the past several years. The concept of damage control resuscitation has expanded significantly with the experience of the US military in southwest Asia. This review will focus on this resuscitation strategy of transfusing blood products (red cells, plasma, and platelets) early and often in the exsanguinating patient.

RECENT FINDINGS

In trauma there are no randomized controlled trials comparing the current damage control hematology concept to more traditional resuscitation methods. But the overwhelming conclusion of the data available support the administration of a high ratio of plasma and platelets to packed red blood cells. Several large retrospective studies have shown ratios close to 1: 1 will result in higher survival.

SUMMARY

The current evidence supports that the acute coagulopathy of trauma is present in a high percentage of trauma patients. Patients who will require a massive transfusion will have improved outcomes the earlier that this is identified and the earlier that damage control hematology is instituted. Current evidence does not describe the best ratio but the preponderance of the data suggests it should be greater than 2: 3 plasma-to-packed red blood cells.

A descriptive analysis of patients admitted to the intensive care unit of the 10th Combat Support Hospital deployed in Ibn Sina, Baghdad, Iraq, from October 19, 2005, to October 19, 2006

BACKGROUND

Although a review of the 1-month experience of a British intensive care unit (ICU) deployed in 2003 to Iraq outlining its care of 47 patients exists, a descriptive study outlining patient characteristics, workload, and outcomes of an ICU during a long-term deployment to Operation Iraqi Freedom is lacking in the medical literature.

METHODS

Between October 19, 2005, and October 19, 2006, the 10th Combat Support Hospital (CSH) deployed in an ICU to Ibn Sina Hospital in Baghdad, Iraq. Staff prospectively collected patient admission data from November 1, 2005, to August 31, 2006, in handwritten logbooks. This information included nationality (United States/Iraqi/other), military versus civilian, mechanism of injury or nontrauma admission diagnosis, ICU length of stay (LOS), and outcome. These data were retrospectively reviewed for the purpose of reporting the experience of the 10th CSH ICU during its deployment.

RESULTS

The 10th CSH ICU admitted 875 patients during the study period. This represented 27% of all hospital admissions (n = 3289). Categories of patients admitted to the ICU included United States military, US contractor, Iraqi military, Iraqi civilian, non-US contractor, coalition military personnel, and security internee. Three patients were unable to be classified due to missing information. The most common patient category of admission was Iraqi civilian (n = 472, 53.9%). Noncoalition (Iraqi civilian, Iraqi military, non-US contractors, and other noncoalition military) admissions made up 76.9% (n = 673) of all admissions. US military (n = 165) and US contractors (n = 31) made up 22.4% of all ICU admissions. Trauma-related admissions were the most common diagnoses (n = 730, 83.4%). Other admission diagnostic categories included medical (n = 125, 14.3%) and postoperative (n = 5, 0.6%) patients. A total of 15 patients (1.7%) were unable to be categorized based on diagnosis due to missing information. The most common medical diagnosis requiring ICU admission was related to cardiovascular disease (n = 51, 40.8%). Seven of the admissions to the ICU were pediatric patients (0.8%). US military personnel traumatically injured suffered significantly more explosion injuries and burns than their Iraqi military and other noncoalition military counterparts. The ICU LOS was significantly shorter in US military and US contractor patients compared to all other groups, likely a result of expeditious air evacuation to a higher level of care. This air evacuation of US personnel combined with the fact that Iraqi patients were transferred to local civilian hospitals prior to the completion of intensive care stay limited follow-up. Despite a lack of meaningful follow-up, the observed ICU all-cause mortality was 5.0% (n = 44).

CONCLUSIONS

The primary mission of a US military ICU deployed in support of combat operations is the care of its injured troops. However, the 10th CSH deployed in an urban region of Iraq in a mature theater of operations and its ICU more commonly cared for non-US patients during combat medical operations. These patients included pediatric patients as well as admissions for nontrauma illnesses. This mission was accomplished by nurses and physicians faced with unique challenges and resulted in an acceptable ICU mortality rate.

Impact of joint theater trauma system initiatives on battlefield injury outcomes

INTRODUCTION

The US military forces developed and implemented the Joint Theater Trauma System (JTTS) and Joint Theater Trauma Registry (JTTR) using US civilian trauma system models with the intent of improving outcomes after battlefield injury.

METHODS

The purpose of this analysis was to elaborate the impact of the JTTS. To quantify these achievements, the JTTR captured mechanism, acute physiology, diagnostic, therapeutic, and outcome data on 23,250 injured patients admitted to deployed US military treatment facilities from July 2003 through July 2008 for analysis. Comparative analysis to civilian trauma systems was done using the National Trauma Data Bank (NTDB).

RESULTS

In contrast to civilian trauma systems with an 11.1% rate of penetrating injury, 68.3% of battlefield wounds were by penetrating mechanism. In the analyzed cohort, 23.3% of all patients had an Injury Severe Score (ISS) > or = 16, which is similar to the civilian rate of 22.4%. In the military injury population, 66% of injuries were combat-related. In addition, in the military injury group, 21.8% had metabolic evidence of shock with a base deficit > or = 5, 29.8% of patients required blood transfusion, and 6.4% of the total population of combat casualties required massive transfusion (>10 U red blood cells/24 hours). With this complex and severely injured population of battlefield injuries, the JTTS elements were used to recognize and remedy more than 60 trauma system issues requiring leadership and advocacy, education, research, and alterations in clinical care. Of particular importance to the trauma system was the implementation and tracking of performance improvement indicators and the dissemination of 27 evidence-based clinical practice guidelines (CPGs). In particular, the damage control resuscitation guideline was associated with a decrease in mortality in the massively transfused from 32% pre-CPG to 21% post-CPG. As evidence of the effectiveness of the JTTS, a mortality rate of 5.2% after battlefield hospital admission is comparable to a case fatality rate of 4.3% reported in an age-matched cohort from the NTDB.

CONCLUSIONS

JTTS initiatives contributed to improved survival after battlefield injury. The JTTS has set the standard of trauma care for the modern battlefield using contemporary systems-based methodologies.

Battlefield resuscitation

PURPOSE OF REVIEW

To bring together in one review article, the most current and relevant evidence relating to military trauma resuscitation.

RECENT FINDINGS

The main themes highlighted by this review are coagulopathy of trauma shock (CoTS), damage control resuscitation, haemostatic resuscitation, the management of massive transfusion, use of adjuvant drugs for haemostasis and use of an empiric massive transfusion protocol.

SUMMARY

The review aims to educate the readership in recent advances in trauma practice, culminating in a novel empiric massive transfusion algorithm seamlessly guiding the clinician through the initial resuscitation stage resulting in reduced mortality, morbidity, coagulopathy and decreased overall blood product usage.

Concomitant cranial and ocular combat injuries during Operation Iraqi Freedom

BACKGROUND

Concomitant cranial and ocular injuries were frequently seen in combat casualties during Operation Iraqi Freedom. The incidence of these injuries is reported along with an interventional case series.

METHODS

A retrospective review was conducted of all surgical patients treated by U.S. Army neurosurgeons and ophthalmologists in Iraq from December 2005 to April 2006.

RESULTS

Out of 104 patients with cranial trauma and 158 patients with ocular trauma, 34 had both cranial and ocular injuries (32.7 and 21.5% of patients with cranial and ocular injuries, respectively). Neurosurgical procedures included exploratory craniotomy, decompressive craniectomy, and frontal sinus surgery. Ophthalmologic surgical procedures included globe exploration, open globe repair, primary enucleation, orbital fracture repair, lateral canthotomy and cantholysis, and repair of lid and periocular lacerations. Patients with cranial trauma had a higher incidence of orbital fracture, orbital compartment syndrome, and multiple ocular injuries compared with patients without cranial trauma (odds ratio 6.4, 3.9, and 3.3, respectively).

CONCLUSION

A strong association exists between cranial and ocular trauma in combat casualties treated during Operation Iraqi Freedom. Combat health support personnel should maintain a high level of suspicion for one of these injuries when the other is present. Co-locating neurosurgeons and ophthalmologists in support of combat operations facilitates the optimal treatment of patients with these combined injuries.

Impact of hypothermia (below 36 degrees C) in the rural trauma patient

BACKGROUND

Hypothermia is an independent predictor of mortality based on urban studies. But this association has not been described in the rural setting. This study's purpose was to evaluate hypothermia as a cofactor to mortality, complications, and hospital length of stay (LOS) parameters in the rural trauma setting.

STUDY DESIGN

The National Trauma Registry of the American College of Surgeons database for our rural, Level I trauma center was queried for a 5-year period (July 2002 to June 2007) to identify adult trauma patients. Multivariate regression models were used to evaluate the association of hypothermia with mortality; infectious complications; organ dysfunction; and, among survivors, hospital LOS parameters.

RESULTS

Of 9,482 adult patients admitted, 1,490 (15.7%) patients were hypothermic. Hypothermia had an adjusted odds ratio of 1.70 for mortality (95% CI, 1.35 to 2.12; p < 0.001). After controlling for covariates, hypothermia was not significantly associated with infectious complications or organ dysfunction, except for arrhythmia (adjusted odds ratio, 1.40; CI, 1.03 to 1.90; p = 0.031). Hypothermia was not associated with a difference in ICU (p = 0.310) or ventilator (p = 0.144) LOS. But a slight increase in hospital days was noted in the hypothermic patient (hazards ratio, 0.890 for discharge; 95% CI, 0.838 to 0.946; p < 0.001).

CONCLUSIONS

Hypothermia is a common problem at admission in a rural trauma center. It is associated with an increase in hospitalized days but not with increased ICU or ventilator days among survivors. Other than arrhythmias, it was not significantly associated with other National Trauma Registry of the American College of Surgeons infectious or organ dysfunction complications. Hypothermia is an independent risk factor for mortality in the rural trauma patient.

Improvised explosive devices and traumatic brain injury: the military experience in Iraq and Afghanistan

OBJECTIVE

The current conflicts in Iraq and Afghanistan have seen frequent use of improvised explosive devices resulting in thousands of casualties, with traumatic brain injuries particularly common. The recent literature is reviewed to provide information to clinicians on the management of this condition.

METHOD

A Medline search from 2001-2008, using the terms Afghanistan, blast injury, improvised explosive devices, Iraq and traumatic brain injury, was performed.

RESULTS

The United States military experience predominates in the literature. The use of body armour and other advances has led to improved survival rates among blast injury victims. Resultant neuropsychiatric injuries, in particular traumatic brain injuries, are discussed. There is debate about the prevalence of traumatic brain injuries. The diagnosis, management, relationship with posttraumatic stress disorder and prognosis of traumatic brain injury are reviewed.

CONCLUSIONS

Traumatic brain injury has been described as the 'signature wound' of the current conflicts in Iraq and Afghanistan. While this term is highly debatable and probably unhelpful, clinicians need to know about this condition to provide the best management.