Impact of Explosive Devices in Modern Armed Conflicts: In-Depth Analysis of Dutch Battle Casualties in Southern Afghanistan

Advanced bleeding control in combat casualty care: An international, expert-based Delphi consensus

BACKGROUND

Hemorrhage from truncal and junctional injuries is responsible for the vast majority of potentially survivable deaths in combat casualties, causing most of its fatalities in the prehospital arena. Optimizing the deployment of the advanced bleeding control modalities required for the management of these injuries is essential to improve the survival of severely injured casualties. This study aimed to establish consensus on the optimal use and implementation of advanced bleeding control modalities in combat casualty care.

METHODS

A Delphi method consisting of three rounds was used. An international expert panel of military physicians was selected by the researchers to complete the Delphi surveys. Consensus was reached if 70% or greater of respondents agreed and if 70% or greater responded.

RESULTS

Thirty-two experts from 10 different nations commenced the process and reached consensus on which bleeding control modalities should be part of the standard equipment, that these modalities should be available at all levels of care, that only trained physicians should be allowed to apply invasive bleeding control modalities, but all medical and nonmedical personnel should be allowed to apply noninvasive bleeding control modalities, and on the training requirements for providers. Consensus was also reached on the necessity of international registries and guidelines, and on certain indications and contraindications for resuscitative endovascular balloon occlusion of the aorta (REBOA) in military environments. No consensus was reached on the role of a wound clamp in military settings and the indications for REBOA in patients with chest trauma, penetrating axillary injury or penetrating neck injury in combination with thoracoabdominal injuries.

CONCLUSION

Consensus was reached on the contents of a standard bleeding control toolbox, where it should be available, providers and training requirements, international registries and guidelines, and potential indications for REBOA in military environments.

Exposure to combat and deployment; reviewing the military context in The Netherlands

This paper reviews the military context of exposure to combat and deployment in Dutch soldiers. It does so by reviewing war victims and military psychiatry after WWII in the Netherlands, and describes Dutch deployments from the late 1970s to the present. 'Who is the Dutch soldier' is asked to articulate the mental load on the individual soldier before, during, and after deployment. The narrative review of this paper allows one to review how the armed forces personnel is challenged in relation to their specific assignment and in what respect the psychological dimensions are addressed and met in the face of risk and adversity. Finally, some critical considerations for future veterans care programmes are raised.

Comparison of the non-mortal gunshot and handmade explosive blast traumas during a low-intensity conflict on urban terrain

OBJECTIVES

We aimed to conduct a cross-sectional data analysis involving 60 patients wounded during a low-intensity conflict on urban terrain.

MATERIAL AND METHODS

Data of the 60 patients wounded during a low-intensity conflict on urban terrain between September 1st, 2016, and January 15th, 2017, and transferred to our hospital after the initial medical interventions conducted in the regional hospitals were probed retrospectively. Group A consisted of 25 (41.67%) patients suffering gunshot wounds, and Group B consisted of 35 (58.33%) patients with blast trauma injuries. Their Abbreviated Injury Scale scores were compared according to the injured body compartment.

RESULTS

In both groups, extremities were the most common site of injury (17 [50%] for Group A, 18 [33.33%] for Group B). The difference between the two groups was statistically significant for only head and neck injuries and facial injuries (p<0.05). In each group, only one body compartment was affected in 19 patients, which represented 55.88% of patients in Group A and 35.18% of patients in Group B. Injuries of three compartments concurrently occurred in 3 (8.82%) patients in Group A and 4 (7.4%) patients in Group B. None of our patients died because of their injuries.

CONCLUSION

Contrary to the expected, gunshot casualties were found to be more likely to suffer from extremity injuries than blast casualties did, and it should be noted that blast trauma casualties tend to have multiple compartment injuries that should not be missed. Ocular ruptures are also common, especially with blast injuries, warranting equipping the personnel with protective goggles.

Amputation: Not a failure for severe lower extremity combat injury

INTRODUCTION

The use of improvised explosive devices is a frequent method of insurgents to inflict harm on deployed military personnel. Consequently, lower extremity injuries make up the majority of combat related trauma. The wounding pattern of an explosion is not often encountered in a civilian population and can lead to substantial disability. It is therefore important to study the impact of these lower extremity injuries and their treatment (limb salvage versus amputation) on functional outcome and quality of life.

PATIENTS AND METHODS

All Dutch repatriated service members receiving treatment for wounds on the lower extremity sustained in the Afghan theater between august 2005 and August 2014, were invited to participate in this observational cohort study. We conducted a survey regarding their physical and mental health using the Short Form health survey 36, EuroQoL 6 dimensions and Lower Extremity Functional Scale questionnaires. Results were collated in a specifically designed electronic database combined with epidemiology and hospital statistics gathered from the archive of the Central Military Hospital. Statistical analyses were performed to identify differences between combat and non-combat related injuries and between limb salvage treatment and amputation.

RESULTS

In comparison with non-battle injury patients, battle casualties were significantly younger of age, sustained more severe injuries, needed more frequent operations and clinical rehabilitation. Their long-term outcome scores in areas concerning well-being, social and cognitive functioning, were significantly lower. Regarding treatment, amputees experienced higher physical well-being and less pain compared to those treated with limb salvage surgery.

CONCLUSION

Sustaining a combat injury to the lower extremity can lead to partial or permanent dysfunction. However, wounded service members, amputees included, are able to achieve high levels of activity and participation in society, proving a remarkable resilience. These long-term results demonstrate that amputation is not a failure for casualty and surgeon, and strengthen a life before limb (damage control surgery) mindset in the initial phase. For future research, we recommend the use of adequate coding and injury scoring systems to predict outcome and give insight in the attributes that are supportive for the resilience that is needed to cope with a serious battle injury.

Transfusion: -80°C Frozen Blood Products Are Safe and Effective in Military Casualty Care

INTRODUCTION

The Netherlands Armed Forces use -80°C frozen red blood cells (RBCs), plasma and platelets combined with regular liquid stored RBCs, for the treatment of (military) casualties in Medical Treatment Facilities abroad. Our objective was to assess and compare the use of -80°C frozen blood products in combination with the different transfusion protocols and their effect on the outcome of trauma casualties.

MATERIALS AND METHODS

Hemovigilance and combat casualties data from Afghanistan 2006-2010 for 272 (military) trauma casualties with or without massive transfusions (MT: ≥6 RBC/24hr, N = 82 and non-MT: 1-5 RBC/24hr, N = 190) were analyzed retrospectively. In November 2007, a massive transfusion protocol (MTP; 4:3:1 RBC:Plasma:Platelets) for ATLS® class III/IV hemorrhage was introduced in military theatre. Blood product use, injury severity and mortality were assessed pre- and post-introduction of the MTP. Data were compared to civilian and military trauma studies to assess effectiveness of the frozen blood products and MTP.

RESULTS

No ABO incompatible blood products were transfused and only 1 mild transfusion reaction was observed with 3,060 transfused products. In hospital mortality decreased post-MTP for MT patients from 44% to 14% (P = 0.005) and for non-MT patients from 12.7% to 5.9% (P = 0.139). Average 24-hour RBC, plasma and platelet ratios were comparable and accompanying 24-hour mortality rates were low compared to studies that used similar numbers of liquid stored (and on site donated) blood products.

CONCLUSION

This report describes for the first time that the combination of -80°C frozen platelets, plasma and red cells is safe and at least as effective as standard blood products in the treatment of (military) trauma casualties. Frozen blood can save the lives of casualties of armed conflict without the need for in-theatre blood collection. These results may also contribute to solutions for logistic problems in civilian blood supply in remote areas.

Combat related vascular injuries: Dutch experiences from a role 2 MTF in Afghanistan

BACKGROUND

In a combat environment, major vascular trauma endures as the leading cause of death. The Dutch role 2 Medical Treatment Facility (MTF), provided supportive care during the mission in Uruzgan, Afghanistan. Aim of this study was to conduct detailed analysis of the admitted major haemorrhages (vascular injuries) and to compare our findings with NATO coalition partners.

METHODS

Retrospective, descriptive study. Participants eligible for this study came from the role 2 MTF admission database, where they fitted the criteria 'Major haemorrhage (class 2 haemorrhage or more according to the ATLS(®) classification) between 2006 and 2010'. Results were contrasted with studies from coalition partners.

RESULTS

The query revealed 194 casualties sustaining 208 central (60% abdominal, 40% thoracic/neck), and 99 extremity major haemorrhages leading to 1.6 major haemorrhages per casualty. Survival was significantly better (p<0.05) in the peripheral vascular injuries cohort (96% versus 72%). Primary amputation was needed in 73/84 of lower, and in 8/15 of upper extremity major haemorrhages. Vascular repair or vascular Damage Control Surgery techniques (e.g. shunting) were used in 19/84 cases in the lower, and 7/15 in the upper extremity cohort, with a success rate of 69.2 percent. Amputation rates of coalition partners, using different inclusion and exclusion criteria, ranged from 5 to 60 percent.

CONCLUSIONS

Only in a few cases genuine peripheral vascular surgery was needed (<1%). This limited number of reconstructions does not demonstrate the need for extensive skills in all areas of vascular surgery. Achieved success rate until discharge was almost 70%. Vascular damage control surgery seems effective as initial limb saving skill in a role 2 MTF. The difference in usage of definitions concerning vascular injuries in current literature warrants further assessment. For optimal analysis there is need for detailed (NATO wide) registration with uniform definitions for vascular injuries.

LEVEL OF EVIDENCE

Level IV--Epidemiologic study.

Post-traumatic stress symptoms 5 years after military deployment to Afghanistan: an observational cohort study

BACKGROUND

Deployment can put soldiers at risk of developing post-traumatic stress symptoms. Despite several longitudinal studies, little is known about the timing of an increase in post-traumatic stress symptoms relative to pre-deployment. Longitudinal studies starting pre-deployment, in which participants are repeatedly measured over time, are warranted to assess the timing of an increase in symptoms to ultimately assess the timing of an increase in treatment demand after deployment.

METHODS

In this large observational cohort study, Dutch military personnel who were deployed to Afghanistan as part of the International Security Assistance Forces between March, 2005, and September, 2008, were assessed for post-traumatic stress symptoms with the Self-Rating Inventory for Post-traumatic Stress Disorder (SRIP) questionnaire. Participants were assessed 1 month before deployment and followed up at 1 month, 6 months, 12 months, 2 years, and 5 years after deployment, with changes in SRIP scores compared with pre-deployment using a mixed model analysis. The primary outcome was the total score of post-traumatic stress symptoms measured with SRIP at pre-deployment and the five follow-up assessments, with a score of 38 used as the cutoff to indicate substantial post-traumatic stress symptoms.

FINDINGS

Between March, 2005, and September, 2008, 1007 participants were recruited to this study. The results show two important effects of deployment on post-traumatic stress symptoms. A short-term symptom increase within the first 6 months after deployment (symptom increase coefficient for SRIP score vs pre-deployment [β] 0·99, 95% CI 0·50-1·48); and a long-term symptom increase at 5 years after deployment (β 1·67, 1·14-2·20).

INTERPRETATION

This study underlines the importance of long-term monitoring of the psychological health of soldiers after deployment because early detection of symptoms is essential to early treatment, which is related to improved psychological health.

FUNDING

Dutch Ministry of Defense.

Long-term impact of battle injuries; five-year follow-up of injured Dutch servicemen in Afghanistan 2006-2010

Objectives

Units deployed to armed conflicts are at high risk for exposure to combat events. Many battle casualties (BCs) have been reported in the recent deployment to Afghanistan. The long-term impact of these combat injuries, at their five-year end point, is currently unknown. To date, no systematic inventory has been performed of an identified group of BCs in comparison to non-injured service members from the same operational theatre.

Design

Observational cross-sectional cohort study.

Setting

Open online survey among Dutch BCs that deployed to Afghanistan (2006–2010).

Participants

The Dutch BCs (n = 62) were compared to two control groups of non-injured combat groups (battle exposed [n = 53], and non-battle exposed [n = 73]).

Main Outcome Measures

Participants rated their impact of trauma exposure (Impact of Events [IES]), post deployment reintegration (Post Deployment Reintegration Scale [PDRS]), general symptoms of distress (Symptom Checklist 90 [SCL-90]), as well as their current perceived quality of life (EuroQol-6D [EQ-6D]). Also cost effectiveness (Short From health survey [SF-36]) and care consumption were assessed (Trimbos/iMTA questionnaire).

Results

Over 90% of BCs were still in active duty. The mean scores of all questionnaires (IES, EQ-6D, SF-36, and SCL-90) of the BC group were significantly higher than in the control groups (p<0.05). The PDRS showed a significantly lower (p<0.05) outcome in the negative subscales. The mean consumption of care was triple that of both control groups. A lower score on quality of life was related to higher levels of distress and impact of trauma exposure.

Conclusions

This study showed a clear long-term impact on a wide range of scales that contributes to a reduced quality of life in a group of BCs. Low perceived cost effectiveness matched with high consumption of care in the BC group in comparison to the control groups. These results warrant continuous monitoring of BCs.