Complex Blast Injuries ROTHBERG.qxp Mise en page 1 … · 2017-12-05 · Blast injuries are...

By P. ROTHBERG∑, J. BAILEY∏, E. ELSTERπ and M. BRADLEY∫. U.S.A.

Philip A. ROTHBERG

Dismounted Complex Blast Injury Patterns: A Reviewof Current Management and Outcome Literature.*

EDUCATION2007 - University of Maryland - College Park, MD, B.S. in Physiology and Neurobiology.

2012 - Tulane University School of Public Health - New Orleans, LA, M.P.H.&T.M. inTropical Medicine.

2012 - Tulane University School of Medicine - New Orleans, LA, MD.EXPERIENCEWalter Reed National Military Medical Center - Bethesda, MD.2012-2013 - General Surgery Intern.2013-Present - General Surgery Resident.

Naval Medical Research Center - Silver Spring, MD.2015-present - Division of Regenerative Medicine.

Guest Researcher.• Investigated immune response to hemorrhage in a rat model.• Investigated SSI prevention in a swine model.

2008-2010 - Tulane Life Support Training Center - New Orleans, LA.Training Center Faculty.

• Trained incoming students in Basic Life Support.• Developed community program for choking prevention.• Taught community first aid and CPR courses.

2009 - Laboratory of Dr. Philip Kadowitz - New Orleans, LA.Research Assistant.

• Performed AV cutdowns and heart catheterizations on rats.• Designed and ran experiments to research test agents.• Performed data analysis and assisted with publication.

2008-2009 - Tulane University School of Medicine, Department of Structural and Cellular Biology - NewOrleans, LA.

Department Teaching Assistant.• Participated in Gross Anatomy, Histology, and Neuroscience courses.• Assisted faculty in by lab instruction, lecturing, and leading reviews.

LEADERSHIPWalter Reed National Military Medical Center - Bethesda, MD.2016-present - ATLS Instructor.2015-2016 - Housestaff Council Rep.2015-2016 - Housestaff Duty Hour Rep.2015-2016 - WRNMMC Annual Institutional Review Housestaff Rep.

Uniformed Services University of the Health Sciences - Bethesda, MD.2015-present - Clinical Teaching Fellow.

POSTERS - 2016 May. Bethesda, MDRothberg PA, Klosterman LA, Richardson M, Elster EA, Bradley MJ. Analysis of pelvic binder placementamong casualties in Afghanistan: a process-improvement initiative. National Capitol Region ResearchCompetition.

PUBLICATIONSNossaman BD, Akuly HA, Lasker GF, Nossaman VE, Rothberg PA, and Kadowitz PJ - The Reemergence ofNitrite as a Beneficial Agent in the Treatment of Ischemic Cardiovascular Diseases. Asian J Exp Biol Sci.

24International Review of the Armed Forces Medical Services Revue Internationale des Services de Santé des Forces Armées

ARTIC

LES

ARTIC

LES

VOL.90/1

Complex Blast Injuries_ROTHBERG.qxp_Mise en page 1 21/03/2017 15:31 Page1

INTRODUCTION

As the wars in Iraq and Afghanistan progressed, enemycombat tactics evolved from conventional small-arms fireand explosive missiles and projectiles to more extensive useof improvised explosive devices (IEDs) of increasing yield12.Blasts were the mechanism of injury for nearly three-quar-ters of all combat wounds13 and wounding patterns diffe-red significantly based on whether or not the injuredcasualty was in a vehicle (mounted) or on foot (dismoun-ted). As the wars progressed in Iraq and particularly inAfghanistan, dismounted injuries became a higher propor-tion of all blast injuries and occurred in predictable patternswith accompanying morbidity and mortality2, 3, 14.

Blast injuries are classified by the specific component ofblast mechanism responsible for damage. In primary blastinjuries, blast overpressure transmits directly onto the per-son. Injuries are most commonly hollow viscus injuries(lungs, tympanic membranes, gut). Secondary injuries arecaused by fragmentation and debris; these materials aretransmitted over a larger distance (approximately 100times the distance at which primary blast injuries would beexpected)15. Tertiary injuries reflect acceleration/decelera-tion injuries of a body onto nearby large objects, or alter-nately, nearby large objects onto a body. Quaternary inju-ries are those received from exposure to harmful productssuch as burn or inhalation injuries. Quinary blast injuries

refer to consequences of exposure to the post detonationenvironment and include bacterial inoculation, radiationexposure, and reactions of tissues to blast componentsfuels or metals16.

Injury patterns in dismounted IED blasts are roughlycategorized into two categories; low-energy and high-energy. Low-energy injury patterns can result eitherfrom a blast that emits relatively less energy or byincreased relative distance from blast. These injury pat-terns include lower extremity open wounds, open orclosed fractures, and/or lower extremity amputations.Perineal or genitourinary soft tissue injuries sustainedfrom this mechanism are in general less severe17.


∑ LT (Dr.) MD, MPH&TM, MC, USN.

∏ Col. (Dr.) MD, MC, USAF.

π Capt. (Dr.) MD, MC, USN.

∫ LCDR (Dr.) MD, MC, USN.

Correspondence:LT (Dr.) Philip ROTHBERG, MD, MPH&TM, MC, USNThe Department of Surgery at Uniformed Services University of the HealthSciences & the Walter Reed National Military Medical Center4301 Jones Bridge RoadBethesda, MD 20814U.S.A.E-mail: [email protected]

* Presented at the 41st ICMM World Congress on Military Medicine,Bali, Indonesia, 17-22 May 2015.

VOL.90/1

RESUME

Caractéristiques des blessures causées par des explosions sur des hommes à pied : revue des pratiquesde soins et conclusions de la littérature.

Les engins explosifs improvisés (EEI) ont été responsables de morbidité et de mortalité importantes tant en Irak qu’enAfghanistan. Les EEI à haute efficacité ont causé des blessures critiques mettant au défi les soins prodigués par les médecins militaires.Les études et recherches originales issues de l’expérience aussi bien des militaires Américains que Britanniques au cours de ces deuxconflits ont été passées en revue.

Les blessures désignées comme « Dismounted complex blast injury (DCBI) » sont les blessures dont ont été victimes des soldats àpied. Il s’agit d’amputations traumatiques unies ou bilatérales des membres inférieurs associées à des lésions des tissus mous dupelvis, du périnée et de la région fessière. Les lésions les plus importantes concernent les organes creux et pleins ainsi que lesatteintes les plus proximales. Ces DCBI ont vu leur fréquence augmenter au cours des opérations Enduring freedom (OEF) et Irakfreedom (OIF) et par conséquence un besoin d’amélioration des connaissances dans le domaine du traitement.

Les soins des soldats victimes de DCBI ont évolué avec les soins aux blessés en situation de combat (TCCC), l’évacuation rapidevers les services chirurgicaux des rôles II et III OTAN et le renforcement des capacités de traitement en cours d’évacuation. Lesprocédures chirurgicales de base sont restées courtes et ciblées; les interventions non vitales ou de sauvetage des membres ontété différées en attendant la stabilisation des patients.

Ces DCBI se sont accompagnées de complications telles que la déhiscence des plaies, les infections fongiques invasives, la maladiethromboembolique, l’ossification hétérotopique et la mort. On a pu montrer que la déhiscence des plaies était associée à un profil desécrétion locale et systémique de cytokines particulier au moment de la suture. Des modèles prédictifs d’infection fongique invasivepouvant aider la décision chirurgicale ont été élaborés. La prévalence des complications thromboembolique est plus élevée dans lesblessures de guerre qu’en traumatologie civile en dépit des mesures chimioprophylactiques. L’application de mesures strictes deprévention a permis de diminuer les complications thromboemboliques chez les blessés de guerre. La mortalité des DCBI se situeentre 8 et 10 %. L’évolution de ce type de blessés a été améliorée grâce à de meilleures pratiques issues de l’expérience que cesoit la prévention, l’entraînement ou les progrès de la réhabilitation.

KEYWORDS: Blast, Trauma, Combat, Amputation, Military.MOTS-CLÉS : Explosion, Traumatisme, Combat, Amputation, Militaire.


INTRODUCTION

As the wars in Iraq and Afghanistan progressed, enemycombat tactics evolved from conventional small-arms fireand explosive missiles and projectiles to more extensive useof improvised explosive devices (IEDs) of increasing yield12.Blasts were the mechanism of injury for nearly three-quar-ters of all combat wounds13 and wounding patterns diffe-red significantly based on whether or not the injuredcasualty was in a vehicle (mounted) or on foot (dismoun-ted). As the wars progressed in Iraq and particularly inAfghanistan, dismounted injuries became a higher propor-tion of all blast injuries and occurred in predictable patternswith accompanying morbidity and mortality2, 3, 14.

Blast injuries are classified by the specific component ofblast mechanism responsible for damage. In primary blastinjuries, blast overpressure transmits directly onto the per-son. Injuries are most commonly hollow viscus injuries(lungs, tympanic membranes, gut). Secondary injuries arecaused by fragmentation and debris; these materials aretransmitted over a larger distance (approximately 100times the distance at which primary blast injuries would beexpected)15. Tertiary injuries reflect acceleration/decelera-tion injuries of a body onto nearby large objects, or alter-nately, nearby large objects onto a body. Quaternary inju-ries are those received from exposure to harmful productssuch as burn or inhalation injuries. Quinary blast injuries

refer to consequences of exposure to the post detonationenvironment and include bacterial inoculation, radiationexposure, and reactions of tissues to blast componentsfuels or metals16.

Injury patterns in dismounted IED blasts are roughlycategorized into two categories; low-energy and high-energy. Low-energy injury patterns can result eitherfrom a blast that emits relatively less energy or byincreased relative distance from blast. These injury pat-terns include lower extremity open wounds, open orclosed fractures, and/or lower extremity amputations.Perineal or genitourinary soft tissue injuries sustainedfrom this mechanism are in general less severe17.


∑ LT (Dr.) MD, MPH&TM, MC, USN.

∏ Col. (Dr.) MD, MC, USAF.

π Capt. (Dr.) MD, MC, USN.

∫ LCDR (Dr.) MD, MC, USN.

Correspondence:LT (Dr.) Philip ROTHBERG, MD, MPH&TM, MC, USNThe Department of Surgery at Uniformed Services University of the HealthSciences & the Walter Reed National Military Medical Center4301 Jones Bridge RoadBethesda, MD 20814U.S.A.E-mail: [email protected]

* Presented at the 41st ICMM World Congress on Military Medicine,Bali, Indonesia, 17-22 May 2015.

VOL.90/1

RESUME

Caractéristiques des blessures causées par des explosions sur des hommes à pied : revue des pratiquesde soins et conclusions de la littérature.

Les engins explosifs improvisés (EEI) ont été responsables de morbidité et de mortalité importantes tant en Irak qu’enAfghanistan. Les EEI à haute efficacité ont causé des blessures critiques mettant au défi les soins prodigués par les médecins militaires.Les études et recherches originales issues de l’expérience aussi bien des militaires Américains que Britanniques au cours de ces deuxconflits ont été passées en revue.

Les blessures désignées comme « Dismounted complex blast injury (DCBI) » sont les blessures dont ont été victimes des soldats àpied. Il s’agit d’amputations traumatiques unies ou bilatérales des membres inférieurs associées à des lésions des tissus mous dupelvis, du périnée et de la région fessière. Les lésions les plus importantes concernent les organes creux et pleins ainsi que lesatteintes les plus proximales. Ces DCBI ont vu leur fréquence augmenter au cours des opérations Enduring freedom (OEF) et Irakfreedom (OIF) et par conséquence un besoin d’amélioration des connaissances dans le domaine du traitement.

Les soins des soldats victimes de DCBI ont évolué avec les soins aux blessés en situation de combat (TCCC), l’évacuation rapidevers les services chirurgicaux des rôles II et III OTAN et le renforcement des capacités de traitement en cours d’évacuation. Lesprocédures chirurgicales de base sont restées courtes et ciblées; les interventions non vitales ou de sauvetage des membres ontété différées en attendant la stabilisation des patients.

Ces DCBI se sont accompagnées de complications telles que la déhiscence des plaies, les infections fongiques invasives, la maladiethromboembolique, l’ossification hétérotopique et la mort. On a pu montrer que la déhiscence des plaies était associée à un profil desécrétion locale et systémique de cytokines particulier au moment de la suture. Des modèles prédictifs d’infection fongique invasivepouvant aider la décision chirurgicale ont été élaborés. La prévalence des complications thromboembolique est plus élevée dans lesblessures de guerre qu’en traumatologie civile en dépit des mesures chimioprophylactiques. L’application de mesures strictes deprévention a permis de diminuer les complications thromboemboliques chez les blessés de guerre. La mortalité des DCBI se situeentre 8 et 10 %. L’évolution de ce type de blessés a été améliorée grâce à de meilleures pratiques issues de l’expérience que cesoit la prévention, l’entraînement ou les progrès de la réhabilitation.

KEYWORDS: Blast, Trauma, Combat, Amputation, Military.MOTS-CLÉS : Explosion, Traumatisme, Combat, Amputation, Militaire.


Injuries sustained by occupants of a mine-resistant vehi-cle, referred to as a mounted IED blast, tend to be pri-mary or tertiary in nature. Penetrating injuries are com-mon only in the setting of un-armored vehicles or blastsfrom explosive formed penetrators (EFP), which concen-trate the fragmentation into a specific vector comparedwith the diffuse spray of common IEDs 18,19,20.

Hallmarks of high-energy blast injury patterns are pelvicring injuries, more severe perineal or genitourinary soft tis-sue injuries, and intra-abdominal solid organ or hollow vis-cus injuries17, 21, 22. Thoracic and CNS injuries are also morecommon in high-energy blasts. Among service memberswith multi-extremity amputations it was found that thehighest percentage of associated injuries were musculos-keletal (31%), skin and soft tissue injuries (18.8%), and GUinjuries 17.4%9. Other less common injuries included: pel-vis and perineal injuries (5.6%), abdominal injuries (4.7%),thoracic injuries (3.7%), spinal injuries (3.2%), neurologicinjuries (2.9%), and vascular injuries (2.7%). The relativepaucity of thoracic and abdominal injuries is likely attribu-table to the effect of modern Kevlar helmets and ceramicplate body armor worn by U.S. service members in Iraq andAfghanistan23, 24. Even smaller proportions of facial frac-tures, ophthalmic injuries, and oropharyngeal injurieswere also seen. Unsurprisingly, the proportion of spinalinjuries correlated with increased severity of injury25. Thissevere wounding pattern with multiple injuries becamemore evident throughout the progression of OEF12, 1.

The DCBI pattern in Afghanistan occurred with increasingfrequency correlating with escalating combat operationsand adaptations in tactics. The pattern and severity wasunlike any injury in previous wars and therefore standar-dized care had not been previously well defined and spe-cific treatment protocols had not developed. However,these issues were quickly addressed by the Department ofDefense Joint Trauma System (JTS), which allowed for realtime international morbidity and mortality conferences.The JTS also provided the impetus for the evolution anddevelopment of military trauma Clinical PracticeGuidelines (CPGs), a common core of principles and treat-ment strategies for all deployed medical providers of allskill level and expertise to follow. Treatment of DCBIpatients is resource-intensive and therefore smaller facili-ties can be quickly depleted of supplies if patients are notevacuated rapidly to higher levels of care9. In this paper,dismounted complex blast injury (DCBI) patterns and theirinitial and ongoing management are discussed. Majorcomplications and efforts to decrease their severity arereviewed. In addition, short and long-term outcomes andareas of performance improvement are explored. Finally,representative findings influencing the care of combatcasualties from retrospective review of OEF/OIF data ispresented.

INITIAL TREATMENT OFDISMOUNTED BLAST INJURY CASUALTIES

Trauma Bay Evaluation

DCBI casualties are frequently critically ill in the pre-hospital setting and in need of rapid evaluation and

resuscitation. Depending on the tactical environmentand number of casualties, pre-hospital care may be pro-vided in the form of self-aid or bystander (combat lifesaver care), which may be the initial and only treatmentprovided in the field particularly if the injuries are lesssevere. Typically though initial treatment of DCBI casual-ties in the field is provided by service members trained inTactical Combat Casualty Care (TCCC). TCCC was adaptedfrom ATLS-based training given to special operationsmedical providers to support battlefield relevant princi-ples of pre-hospital care. In consultation with specialoperations providers, TCCC was fashioned by NavalSpecial Warfare Command to provide tactical traumacare in a small-teams environment26. TCCC is divided intothree phases; Care Under Fire, Tactical Combat Care, andCasualty Evacuation Care. These phases delineate theprinciples of TCCC; namely, return suppressive fire, pro-vide immediate tactically feasible hemorrhage controland remove the casualty to safety followed by airwaycontrol, treatment of open and tension pneumothorax,fluid resuscitation, re-assessment and control of hemor-rhage, prevention of hypothermia, protection of eyeinjury, pain management and rapid evacuation. TCCC isdiscussed in more detail later.

Current Advanced Trauma Life Support (ATLS) guidelinesand U.S. Army Institute of Surgical Research ClinicalPractice Guidelines provide the framework for initialtrauma bay management. The Defense MedicalReadiness Training Institute (DMRTI) based in Fort SamHouston, TX has worked to integrate tactical traininginto the ATLS framework in its ATLS – OperationalEmphasis (OE) course. The OE supplement contains addi-tional lectures on tactical damage control resuscitation,military trauma systems, and team concepts. A practicalcourse in proper tourniquet use was also included27. Thiscourse is intended to be provided to all medical, nursing,and allied health professionals in the U.S. military.

Given the likelihood of multiple severe traumaticamputations, hemorrhage control is an immediatepriority with dismounted complex blast casualties.Initial assessment by providers includes assurance thattourniquets are in place and tightly secured. For blee-ding not amenable to tourniquet control such as highabove knee amputations, junctional mechanicalhemostatic devices should be applied. Given the asso-ciation between lower extremity amputation and pel-vic fractures, pelvic instability should also be assessedand a pelvic binder placed if not already secured in thefield. Airway patency is assured or secured with intuba-tion or surgical airway, while preventing untowardanesthetic related hypotension. Etomidate is therecommended induction agent and ketamine is givenfor analgesia in hypotensive patients. Optimal painmanagement remains a controversial issue; concernsamong medics regarding hypotension with opioids andlack of familiarity with Ketamine has led to pain medi-cation frequently being withheld at the point ofinjury28. Severely injured patients will typically arrivewith supraglottic, endotracheal, or surgical cricothyroi-dotomy airway devices placed by pre-hospital providers.Vascular or intra-osseous access for resuscitation has


VOL.90/1


often been placed prior to presentation to the Role II orIII facility. With the amount of soft tissue destruction andhypotension sustained by blast casualties, intraosseousaccess is frequently obtained in the field or en route tothe receiving facility. In the emergency room additionalperipheral large-bore intravenous access is obtained ifpossible otherwise central venous access is placed29.Patients rapidly undergo balanced resuscitation withblood products17. Patients arriving with CPR in progressare assessed for signs of life (cardiac activity on FAST,EKG, pupillary reactivity, spontaneous respirations) andare often treated with a resuscitative thoracostomy (RT)in the trauma bay30.

RT allows for proximal vascular control by cross-clampingthe descending thoracic aorta while permitting opencardiac massage (OCM) in an attempt to improve perfu-sion to the heart and brain30. [For the highest probabi-lity of survival, the general indications for an ED RT areblunt trauma patients arriving to the trauma bay withless than ten minutes of pre-hospital cardiopulmonaryresuscitation (CPR), penetrating torso trauma patientswith less than fifteen minutes of pre-hospital CPR, andpenetrating neck or extremity trauma with less than fiveminutes of CPR31, 32. In recent US combat operations, thesurvival rate reported for RT performed on casualtiesarriving with signs of life after penetrating trauma,including bilateral amputations, was 11%, similar to sur-vival rates in civilian trauma33. The ResuscitativeEndovascular Balloon Occlusion of the Aorta (REBOA)device can also be inserted, which is being placed withincreased frequency in the civilian trauma population, asan alternative or in conjunction with a resuscitative tho-racotomy and OCM34-36. However, with the adoption ofDamage Control Resuscitation (DCR), rapid blood pro-duct transfusion, and tourniquet placement for DCBIcasualties RT was often not necessary37.

INDEX SURGICAL PROCEDURE PRIORITIES

Vascular Control

Following initial resuscitation, patients are taken emer-gently to the operating room. Life-threatening hemor-rhage remains one of the top causes of potentially survi-vable death in combat trauma; therefore, hemostasis isparamount. Hemorrhage from extremity amputationsare managed by tourniquets until the casualty under-goes operative exploration38. Field tourniquets areconverted to pneumatic tourniquets either in thetrauma bay or upon arrival in the operating room.Hemostatic packing material placed in the field is remo-ved from the wound while exploring the wound in theoperative theater. Vascular control is then obtained byplacing vascular clamps initially as proximally as possiblein clear vascular planes and then “marching the clamps”distally to isolate and localize the area of injury38, 39.Vascular management varies depending on the level ofamputation or vascular injury. Depending on resourcesand presence of other life-threatening injuries optionsfor repair of vascular injuries include primary repair,exploration and placement of a vascular shunt, throm-bolectomy, or repair with an interposition autologous orprosthetic graft40, 41, 42. Proximal traumatic amputations

or junctional vascular injuries are managed by aortic orcommon iliac vessel control through a transperitoneal orretroperitoneal approach43. In certain instances, primaryligation or even amputation may be warranted based onthe amount of soft tissue destruction and physiologic sta-tus of the patient. The severe nature of DCBI often madelimb salvage prohibitive37. If temporary vascular shuntsare used in extremity arteries, fasciotomies should be per-formed41, 42, 44, 45, 46. Owing to the potential risks of vas-cular complications while undergoing aeromedical eva-cuations, fasciotomies should be completed in this settingas well41, 47.

Pelvic stabilization

In patients with high bilateral lower extremity amputa-tions consistent with DCBI, the rate of concurrent pelvicfracture approaches 30% with bilateral lower extremityamputations and 39% with bilateral transfemoralamputation48. Unstable pelvic fractures are potentiallylife-threatening injuries due to the potential for retro-peritoneal hemorrhage and exsanguination49. Initialtreatment of unstable pelvic fractures in the field or enroute includes placement of a pelvic binder, whichworks by reducing pelvic volume and providing a tam-ponade effect. Unfortunately physical exam historicallyhas not been very accurate in identifying pelvic frac-tures, thus, recommendations for empirically placing abinder in the field include casualties with bilateral lowerextremity amputations17, 50, 51, 52. At Role II or III facilitieswith orthopedic capabilities rapid application of anexternal fixation (ex-fix) device can be life-saving, espe-cially in casualties presenting with a malpositioned bin-der or no binder at all. Placement of an ex-fix can occurin the emergency department or the operating room.Similar to a binder an ex-fix achieves hemostasis byreducing pelvic volume and stabilizing bony elementsthereby providing a tamponade effect. External pelvicfixation also allows for prone positioning of patientswhich may be required for management of extensiveperineal, gluteal, or flank soft tissue injuries53. Ongoingpelvic hemorrhage despite appropriate pelvic stabiliza-tion with an ex-fix presents a unique challenge in anaustere environment. Endovascular embolization maynot be routinely available even at Role 3 facilities54. Inthis instance, pre-peritoneal packing has been found tobe of benefit in preventing further hemorrhage54-56.Bilateral internal iliac artery ligation during laparotomyand in conjunction with pelvic packing is an additionaldamage control tool for massive life threatening retro-peritoneal hemorrhage54, 57. Hemorrhage control andpelvic fixation are the key points of this aspect of theindex surgical procedure.

Fecal diversion

In the setting of pelvic disruption or open pelvic woundsit is recommended to perform fecal diversion. At thetime of the index procedure the sigmoid colon is stapledat the pelvic brim and left in discontinuity if performingdamage control surgery. A colostomy can be matured atsubsequent operations once physiologic derangementshave been corrected58. A loop colostomy may be accep-table in the absence of evolving rectal injuries but


VOL.90/1


often been placed prior to presentation to the Role II orIII facility. With the amount of soft tissue destruction andhypotension sustained by blast casualties, intraosseousaccess is frequently obtained in the field or en route tothe receiving facility. In the emergency room additionalperipheral large-bore intravenous access is obtained ifpossible otherwise central venous access is placed29.Patients rapidly undergo balanced resuscitation withblood products17. Patients arriving with CPR in progressare assessed for signs of life (cardiac activity on FAST,EKG, pupillary reactivity, spontaneous respirations) andare often treated with a resuscitative thoracostomy (RT)in the trauma bay30.

RT allows for proximal vascular control by cross-clampingthe descending thoracic aorta while permitting opencardiac massage (OCM) in an attempt to improve perfu-sion to the heart and brain30. [For the highest probabi-lity of survival, the general indications for an ED RT areblunt trauma patients arriving to the trauma bay withless than ten minutes of pre-hospital cardiopulmonaryresuscitation (CPR), penetrating torso trauma patientswith less than fifteen minutes of pre-hospital CPR, andpenetrating neck or extremity trauma with less than fiveminutes of CPR31, 32. In recent US combat operations, thesurvival rate reported for RT performed on casualtiesarriving with signs of life after penetrating trauma,including bilateral amputations, was 11%, similar to sur-vival rates in civilian trauma33. The ResuscitativeEndovascular Balloon Occlusion of the Aorta (REBOA)device can also be inserted, which is being placed withincreased frequency in the civilian trauma population, asan alternative or in conjunction with a resuscitative tho-racotomy and OCM34-36. However, with the adoption ofDamage Control Resuscitation (DCR), rapid blood pro-duct transfusion, and tourniquet placement for DCBIcasualties RT was often not necessary37.

INDEX SURGICAL PROCEDURE PRIORITIES

Vascular Control

Following initial resuscitation, patients are taken emer-gently to the operating room. Life-threatening hemor-rhage remains one of the top causes of potentially survi-vable death in combat trauma; therefore, hemostasis isparamount. Hemorrhage from extremity amputationsare managed by tourniquets until the casualty under-goes operative exploration38. Field tourniquets areconverted to pneumatic tourniquets either in thetrauma bay or upon arrival in the operating room.Hemostatic packing material placed in the field is remo-ved from the wound while exploring the wound in theoperative theater. Vascular control is then obtained byplacing vascular clamps initially as proximally as possiblein clear vascular planes and then “marching the clamps”distally to isolate and localize the area of injury38, 39.Vascular management varies depending on the level ofamputation or vascular injury. Depending on resourcesand presence of other life-threatening injuries optionsfor repair of vascular injuries include primary repair,exploration and placement of a vascular shunt, throm-bolectomy, or repair with an interposition autologous orprosthetic graft40, 41, 42. Proximal traumatic amputations

or junctional vascular injuries are managed by aortic orcommon iliac vessel control through a transperitoneal orretroperitoneal approach43. In certain instances, primaryligation or even amputation may be warranted based onthe amount of soft tissue destruction and physiologic sta-tus of the patient. The severe nature of DCBI often madelimb salvage prohibitive37. If temporary vascular shuntsare used in extremity arteries, fasciotomies should be per-formed41, 42, 44, 45, 46. Owing to the potential risks of vas-cular complications while undergoing aeromedical eva-cuations, fasciotomies should be completed in this settingas well41, 47.

Pelvic stabilization

In patients with high bilateral lower extremity amputa-tions consistent with DCBI, the rate of concurrent pelvicfracture approaches 30% with bilateral lower extremityamputations and 39% with bilateral transfemoralamputation48. Unstable pelvic fractures are potentiallylife-threatening injuries due to the potential for retro-peritoneal hemorrhage and exsanguination49. Initialtreatment of unstable pelvic fractures in the field or enroute includes placement of a pelvic binder, whichworks by reducing pelvic volume and providing a tam-ponade effect. Unfortunately physical exam historicallyhas not been very accurate in identifying pelvic frac-tures, thus, recommendations for empirically placing abinder in the field include casualties with bilateral lowerextremity amputations17, 50, 51, 52. At Role II or III facilitieswith orthopedic capabilities rapid application of anexternal fixation (ex-fix) device can be life-saving, espe-cially in casualties presenting with a malpositioned bin-der or no binder at all. Placement of an ex-fix can occurin the emergency department or the operating room.Similar to a binder an ex-fix achieves hemostasis byreducing pelvic volume and stabilizing bony elementsthereby providing a tamponade effect. External pelvicfixation also allows for prone positioning of patientswhich may be required for management of extensiveperineal, gluteal, or flank soft tissue injuries53. Ongoingpelvic hemorrhage despite appropriate pelvic stabiliza-tion with an ex-fix presents a unique challenge in anaustere environment. Endovascular embolization maynot be routinely available even at Role 3 facilities54. Inthis instance, pre-peritoneal packing has been found tobe of benefit in preventing further hemorrhage54-56.Bilateral internal iliac artery ligation during laparotomyand in conjunction with pelvic packing is an additionaldamage control tool for massive life threatening retro-peritoneal hemorrhage54, 57. Hemorrhage control andpelvic fixation are the key points of this aspect of theindex surgical procedure.

Fecal diversion

In the setting of pelvic disruption or open pelvic woundsit is recommended to perform fecal diversion. At thetime of the index procedure the sigmoid colon is stapledat the pelvic brim and left in discontinuity if performingdamage control surgery. A colostomy can be matured atsubsequent operations once physiologic derangementshave been corrected58. A loop colostomy may be accep-table in the absence of evolving rectal injuries but


VOL.90/1


should be not performed during a damage control pro-cedure59, 60, 61. It is important to keep in mind potentialfuture orthopedic incisions in these casualties whenselecting ostomy placement to prevent future woundcontamination17.

In the civilian trauma literature, performance of diver-ting colostomies for open pelvic fractures has beenlosing favor62. It is felt that due to the extensive natureof injuries seen in DCBI casualties that civilian data onopen pelvic fractures may not be applicable. Emergingdata from the UK among blast-wounded service mem-bers in Afghanistan has begun to question the need forcolostomy for preventing infection in perineal wounds.A small series demonstrated that rates of perinealwound infections among patients whose fecal streamswere diverted by colostomy versus by rectal tube werenot significantly different56. In civilian trauma colos-tomy reversal within two weeks has been shown to besafe provided the patients’ wounds are healing, sepsisis resolved, and the patient is stable63. This is often notthe case with combat wounds due to the destructivenature of the blasts; thus, few if any combat casualtiesare reversed early after injury. Exact timing of ostomyreversal in the blast population is unknown but data onappropriate timing and associated complications ofcolostomy reversal in combat casualties is forthcoming.

Surgical debridement

Dismounted IED blasts often cause large deglovinginjuries of the lower extremities and perineum. Theblast itself inoculates soil and clothing deep into thewounds and produces a diffuse microvascular injury64.Non-viable tissues are sharply debrided and woundsare thoroughly irrigated of dirt and debris65. Copiousirrigation of tissue decreases bacterial load andremoves organic matter. Adequate debridement ofnon-viable tissue reduces substrate for bacterialgrowth, allows for eventual closure, and improves theoverall clinical status of the patient66. Negative pres-sure wound therapy is used liberally to allow woundsto heal either by secondary intention or develop suffi-cient granulation tissue for skin or synthetic dermisgrafting or for delayed primary closure65, 67. As discus-sed below, debridement at the index operation is thefirst of many serial debridements68.

SECONDARY SURGICAL PRIORITIES

As noted above, the intent of index operations is toattain hemostasis, stabilize pelvic fractures, divert fecalstream, and debride devitalized tissue in an unstablepatient. Other injuries are temporized or protecteduntil definitive care can be provided. Ocular injuriesremain protected with eye shields or improviseddevices such as disposable paper cups69-71. Emphasis isgiven to limb preservation in upper extremity injuries;avoidance of amputation is crucial to patients’ functio-nal recovery72-74. Genitourinary injuries will have beencontrolled according to the level of injury75. Ureteraland bladder injuries in which primary repair over astent is not feasible will be drained with percutaneousnephrostomy or distal ligation and ureterostomy76, 77.

Urethral injuries will be temporized with suprapubicbladder catheter placement78. In later operations whenpatients are more stable, less urgent operative interven-tions can be undertaken. Secondary surgical prioritiesare repeated in numerous surgeries that are to followthe index operation.

Serial debridements

It is expected that patients will undergo serial returnsto the operating room for repair of injuries and woundirrigation and debridements. Timing is clinically dicta-ted but most commonly occurring every 24-48 hours inthe more acute phases of illness and every 48-72 hourslater in the course of hospital stay79, 80. These serialoperations also occur within 24 hours of arrival at eachsubsequent facility to allow fresh evaluation of woundsby successive surgeons. At the onset of both conflicts,war wounds were treated with wet-to-dry gauze dres-sings changed twice daily. From 2003 onwards, utiliza-tion of negative pressure wound therapy (NPWT)increased dramatically to become the standard of carefor wound dressings81, 82. NPWT provides the addedbenefit of improving patient comfort by allowing theinterval between painful dressing changes to lengthenfrom twice daily to once every 48-72 hours. This provedimportant as DCBI patients required an average of 8.6operative procedures until definitive wound closure9.

Amputation revision

Traumatic amputations follow many of the same tenetsnoted in the section regarding serial wound debride-ments; that is, debridement of all non-viable tissue andcopious isotonic irrigation. Extremity vessels are ligatedas distally as is possible while remaining proximal to thelimit of preserved bone. Use of proximal external fixa-tion and preservation of as much viable bone and softtissue as possible maximizes residual limb length.Eccentric skin and tissue flaps may be present and theirpreservation is paramount for later reconstruction. Allwounds should initially be treated with negative pres-sure wound therapy (NPWT). If unavailable, saline orDakins-soaked gauze dressings can be used instead83.Delayed sequelae of blast wounds include the develop-ment of heterotopic ossification (HO), the ectopicdeposition of bone in non-bone tissue, which results inpain, ulceration, or poor fitting of prostheses. The pre-valence of HO in war-wounded patients is 63-65%84, 85.Symptomatic HO not amenable to prosthetic modifica-tion or medical therapy requires surgical excision84. Ingeneral, the results of HO excision are acceptable withlow rates of recurrent, symptomatic HO84. Additionalcomplications in amputated limbs included infection,dehiscence, neuroma formation, as well as poor cosme-tic and functional outcomes86. As a result, over half oflower extremity amputations require a revision86.

Non-critical fracture treatment

Fractures that do not contribute significantly to bleedingor physiologic compromise (fractures other than spine,long bones, and pelvis) are not addressed at the indexsurgical procedure in an unstable patient. These fractures


VOL.90/1


are typically initially managed at a secondary surgerywith external fixation or wire fixation. Definitive internalfixation is delayed until the patient is more physiologi-cally stable which has not resulted in major orthopediccomplications87, 88.

MAJOR COMPLICATIONS

DCBI resolution is hampered by wound complications,localized and systemic infections, heterotopic ossification,venous thromboembolism, and death. Significant efforthas been expended to better classify these complicationsand prevent or treat them.

Invasive Fungal Infections

Previously a rare complication of traumatic injury invol-ving farms, industry, or natural disasters, invasive fungalinfections (IFI) have become more common in the settingof blast trauma and massive blood product transfusion.The rates of IFI among trauma admissions in Afghanistanreached as high as 3.5%89 and were associated with ahigh mortality rate of 11-38%90. It has been demonstratedthat patients with IFI experienced a statistically significantincrease in number of operative procedures, longer ICUstay, and increased rates of more proximal amputationrevision and death91. Definitions of invasive fungal infec-tions had previously targeted the presence of IFI in prima-rily or secondarily immunosuppressed patients (typicallycancer patients). Case definitions developed by theEuropean Organization for Research and Treatment ofCancer/Invasive Fungal Infections Cooperative Group andthe National Institute of Allergy and Infectious DiseasesMycoses Study Group (EORTC/MSG) Consensus Group clas-sified IFI by level of evidence of clinical infection andincludes proven IFI (the presence of fungal elements indiseased tissue), probable IFI, and possible IFI92. IFI in thecombat setting was adapted from the Mycosis StudyGroup classification. To meet criteria combat casualtiesmust have traumatic wounds that have undergone grea-ter than one debridement with tissue necrosis noted inthe wound on two or greater subsequent debridementsas well as evidence of IFI as follows: proven IFI confirmedwith angioinvasion on histopathology, probable IFI sug-gested with tissue invasion without angioinvasion, andpossible IFI suggested with a positive fungal culture in theabsence of positive histopathology89.

Treatment is centered on appropriate surgical debride-ment, initiation of topical and systemic antifungal the-rapy, and correcting predisposing factors93. Appropriatesurgical debridement is frequent (~every 24 hours initially)and aggressive94. Devitalized tissue lacks blood flow todeliver systemic antifungal therapy and therefore must bethoroughly debrided89. Topical antifungal therapyconsists of irrigation with modified Dakin’s solutionduring operative debridement, instillation of modifiedDakin’s solution via NPWT, or use of Dakin’s-soaked dres-sings. Topical antifungal therapy is instituted if three orgreater risk factors exist for IFI, which include: dismountedblast injury; proximal lower extremity amputation;extensive perineal, genitourinary, or rectal injury; andtransfusion of greater than 25 units of blood94. Systemicantifungal therapy is started for histopathologic evidence

of IFI or progressive tissue necrosis over 2 or more conse-cutive debridements and consists of Voriconazole andliposomal Amphotericin B95, 96.

Invasive fungal infections carry significant increases inmorbidity, mortality, and utilization of healthcareresources. In an attempt to provide predictive tools tobetter stratify those at high risk for IFI; case-control datafrom DoDTR was reviewed. Large volume blood producttransfusions and dismounted IED injuries resulting inproximal lower extremity amputations were identifiedas risk factors for developing invasive fungal infections90.[A retrospective review of data from Landstuhl RegionalMedical Center (LRMC) was performed to assess if timingof diagnosis of IFI in both the pre- and post-CPG institu-tion (before and after February of 2011) had an effect onoutcomes. According to the study results, the institutionof the CPG allowed earlier identification of IFI; however,earlier diagnosis and treatment did not decrease lengthof hospital stay or overall mortality97. The authors belie-ved that some implementation of earlier IFI screeningprior to publication of the CPG might have decreasedthe power of their study.

Serum biomarkers may also be of use in predicting whichtrauma patients are at high risk for invasive fungal infec-tions. A retrospective case-control study comparedimmune biomarkers from DCBI patients with andwithout IFI. Serum values of IFN-α, IL-10, IL-15, andRANTES were significantly higher in patients with IFI thanin those without. Elevations of these biomarkers wereshown to be excellent predictors of IFI98. The authors sug-gest future use of these biomarkers as a blood test forthe presence of IFI in order to guide earlier treatment.

Data-driven computer algorithms have been shown tobe beneficial in guiding clinical diagnosis99-101. TheSurgical Critical Care Initiative (SC2I) was able to developa tool to predict the likelihood of IFI based on presenceof traumatic pelvic and/or genital injuries, rectal injury,above knee amputation, theatre base deficit, theatrecolostomy placement, theatre shock index, and first 24hour pRBC transfusion requirement. This tool provides apercent likelihood that an IFI is present. In concert withclinical judgment, decisions about instituting treatmentcan be made (http://sc2i.org/tools). It is probable thatmany similar tools will be developed to aid clinicians indiagnosis and management of complex patients.

Measures of Quality Care

The use of benchmarking in clinical practice to evaluatequality of care provided has expanded into militarytrauma care as well. Diagnosis and treatment of compli-cations such as symptomatic heterotopic ossification andvenous thromboembolic disease allow military physiciansto assess the care that the combat wounded patientreceives.

Heterotopic ossification occurs as a result of blunt or pene-trating trauma, neurologic trauma, and burns102, 103. HOcomplicates lifestyle and return to duty by causing pain,poorly fitting prostheses, as well as vascular, neurologic,


VOL.90/1


and skin injury103, 104. The prevalence of HO in patientswith traumatic combat amputations approaches 65%85.Methods of HO prevention include NSAIDs and radiothe-rapy; however, once formed the definitive treatment forHO is surgical excision105-107. Recent research has implica-ted increased bioburden as a contributor to increased like-lihood of HO formation in an animal model108. Theseexperiments suggest that contaminated soft tissuewounds in blast trauma may also increase the likelihoodof HO formation. Early and aggressive management ofwounds (debridement, thorough irrigation, and appro-priate antibiotics) may help decrease the burden of futureHO development108.

Venous thromboembolic (VTE) disease is characterizedby deep venous thrombosis (DVT) and pulmonaryembolism (PE). DVT and PE are a major cause of morbi-dity and mortality in the trauma population109.Although precise incidences of VTE disease in DCBIpatients has not been explored, in combat woundedpatients with bilateral lower extremity amputationsthe rate of VTE is 17.9%1, 110. Patients that develop VTEdisease remain at risk for the sequelae which includepost-thrombotic syndrome, chronic thromboembolicpulmonary hypertension, and an elevated risk of recur-rence111, 112. Blast-wounded patients from OEF and OIFseem to have a rate of PE/DVT that exceeds that expec-ted for the trauma population as a whole despite adhe-rence to VTE prophylaxis8. Independent risk factors forPE were discovered to be bilateral lower extremityamputations, pelvic fractures, and long-bone frac-tures110. VTE chemoprophylaxis is routinely given towar wounded patients as soon as possible after injuryprovided there is no ongoing risk of bleeding113. Therecommendation for VTE prophylaxis is Lovenox 30mgdelivered subcutaneously twice daily. For patients withcentral nerve catheters in place it is advised to changethe dose of Lovenox to 40mg SQ daily which decreasesbleeding complications while maintaining adequateVTE prophylaxis114, 115. A recent report comparingenoxaparin (low molecular weight heparin) to unfrac-tionated heparin SQ three times daily in civilian traumapatients demonstrated no difference in VTE rates bet-ween groups116. However, the current first line chemi-cal prophylactic treatment remains Lovenox. In patientswith bleeding diathesis or contraindications to VTEchemoprophylaxis, placement of removable inferiorvena caval filters should be considered117, 118.

Mortality

Mortality rates of OEF/OIF were lower than those of theconflicts of the previous century even at the outset ofboth conflicts. The case-fatality rate for OEF/IEF was 10% ascompared to 15.8% for Vietnam and 19.1% for WWI5, 119.Mechanisms of wounding changed as the wars progressed;enemy combatants shied away from more traditional directcombat engagement began to conceal IEDs and ambushNATO patrols24, 120. Blast wounds accounted for 56% ofinjuries from 2003-2004; this proportion increased to76% in 200612, 24, 120. The proportion of injuries due togunshot wounds decreased from 30% to 24% over thesame period12, 13, 110.

Throughout the course of the wars the mean ISS, num-ber of total injuries per patient, and number of extremi-ties injured per patient increased12. Casualties were sus-taining more severe injuries mostly from more devasta-ting IEDs than combatants had previously encountered.The substantial decline in case-fatality rate in the settingof more grievous wounding patterns seen in the latterparts of OEF/OIF is a testament to improved preventionand treatment of traumatic injury121, 122.

Conceptualizing death from battlefield injuries requiressome common nomenclature. Fatalities as a result of bat-tle injuries were stratified into those that occurred priorto arrival at a military treatment facility (MTF) and wereconsidered killed in action (KIA) versus those that occur-red after MTF arrival and died of wounds (DOW)10. 87%of all combat deaths were KIA; of these 76% were classi-fied as potentially survivable (PS) vs. 24% deemed non-survivable (NS)5. Non-survivable injuries (NS) fall into thebroad categories of total body disruption, catastrophicCNS or high cervical spinal cord injury, cardiac or intra-thoracic tracheal or vascular injury, solid organ avulsion,or traumatic hemipelvectomy5. Of the PS injuries, hemor-rhage accounted for 83-90%. Sources of hemorrhagewere noncompressible, truncal hemorrhage (49-67%),junctional hemorrhage (19-21%), and compressibleextremity hemorrhage (14-33%)5, 12. Additional majorcauses of PS death were airway (10-15%), CNS injury (6-13%), and sepsis or multi-system organ failure (2-6%)12.Interventions to prevent PS death therefore must targetthese causes in a methodical and thorough fashion123.

ELEMENTS OF A SYSTEMATIC APPROACHTO IMPROVING DCBI CARE

Adaptation of TCCC

The vast majority (75-87%) of combat deaths occurprior to arrival at a Role III facility5. TCCC, as mentionedabove, was designed to decrease mortality from poten-tially survivable injuries in combat with a focus on pre-hospital interventions.

The 75th Ranger Regiment is a US army light infantry spe-cial operations force124. In 1998 the unit’s regimentalcommander shifted responsibility for casualty responsefrom unit medics to the unit’s tactical leadership and ins-tituted continuous training in TCCC10. Kotwal and col-leagues examined nine years of battlefield casualties inAfghanistan comparing case mortality rate of the 75th

Ranger Regiment to the remainder of DoD casualtiesand found a rate of 3% versus 19-28%, respectively10, 12.Furthermore; the small percent of fatalities reported byKotwal et al were not the result of extremity hemor-rhage, tension pneumothorax, or airway obstructionwhich represented the three major causes of preventa-ble death10. Definitions of PS deaths did not differ bet-ween the studies. This significant decline in mortalitywas attributed to TCCC training and supported thecontinued effort to expand TCCC training and utilizationthroughout the entire DoD.

TCCC is divided into three phases; Care Under Fire,


VOL.90/1


Tactical Field Care, and Tactical Evacuation Care. The fol-lowing is derived in brief from the Military HealthSystem Guidelines on TCCC: Care Under Fire (CUF) refersto the period of time in which the first responder andcasualty are still engaged by the enemy and under fire4.The priorities of this phase of care are stopping life-threatening hemorrhage, attaining fire superiority andmoving the casualty to relative safety. Only life-threate-ning hemorrhage control should be attempted duringthis phase to prevent exsanguination and death. Firesuperiority must be attained by the first responder (and,if able, the casualty) prior to addressing any injury.Afterwards, casualties should be moved to areas of rela-tive safety to avoid ongoing potential sources of injury(enemy fire, burning structures/v ehicles, etc).

The second phase, Tactical Field Care, begins once enemyfire is suppressed and the casualty is in relative safety. Theacronym MARCH (Massive Hemorrhage, Airway,Respiration, Circulation, Head Injury/Hypothermia) des-cribes the priorities of this phase of care125. MassiveHemorrhage refers to control of life-threatening bleedingwith placement of extremity tourniquets, junctional tour-niquets, or topical hemostatics. Tourniquets placed duringCare Under Fire are reassessed and additional, or “side-by-side” tourniquets may be placed. Airway refers to place-ment of airway adjuncts or establishment of definitive air-way (either supra- or infraglottic or surgical). Respiratorydirects decompression of tension pneumothorax withneedle thoracostomy, placement of a vented chest seal onopen chest wounds, and ventilatory support by bag-valvemask126. Circulation refers to establishment of intrave-nous or intraosseous access and fluid administration gui-ded by the principle of permissive hypotension (goal ofpalpable carotid pulse). Casualties with altered mentalstatus or enemy combatants are disarmed to preventongoing threat to providers125.

The third phase, Tactical Evacuation (TE), prepares sta-bilized patients for transport to advanced medical andsurgical care125. Planning for evacuation ideally occursearly to account for delays in arrival of the evacuationplatform and prolonged transport. Adjuncts such asTXA and intravenous antibiotics are given during thisphase. Patient packaging is performed with thermalblankets to prevent hypothermia. Providers must bediligent about assessing their patients for evidence ofdecompensation such as decreasing Glasgow ComaScale (GCS), changes in respiratory status, or weakenedpulses suggestive of ongoing hemorrhage.

Aeromedical evacuation (2nd)

Helicopters were first used to evacuate casualties duringthe Korean War. The U.S. military improved on this plat-form during the Vietnam War by adding trained flightmedics to provide en route care127, 128. Evacuationimproved even further during OIF/OEF with faster andmore highly skilled battlefield transport.

Movement of combat casualties is divided into casualty eva-cuation (CASEVAC) and medical evacuation (MEDEVAC).CASEVAC refers to any non-medical vehicle tasked to bring

casualties to medical care while MEDEVAC refers to anyvehicle solely equipped and manned for casualty evacua-tion129. MEDEVAC crew and vehicles are not armed withoffensive weapons and explicitly marked with a red cross.Specifically for air transport rotary wing platforms were themost common means for casualty evacuation. DuringOEF/OIF these were the US Army MEDEVAC call sign “DUS-TOFF” (due to the dust and dirt blown from the rotors), USAir Force Pararescue Expeditionary Rescue Squadron (ERS)call sign “PEDRO,” and UK Medical Emergency ResponseTeams (MERT) call sign “Tricky”.

Medical care on a DUSTOFF platform during OEF/OIF wasprimarily delivered by a flight medic trained to the levelof an Emergency Medical Technician – Basic (EMT-B),which are currently being converted to paramedics.EMT-B skills include CPR, intravenous access, basic airwayprotection, and stabilization of musculoskeletal inju-ries130. These basic skill sets are augmented to includeadditional training in hemorrhage control. DUSTOFF wasaugmented, in a scalable manner depending on missionand resource availability, by US Army En Route CareCCRNs and US Air Force Tactical Casualty Care EvacuationTeams “TCCET” after 2010. These included participationin point of injury and intra-theater transport missions. Inaddition, after 2013 the Vampire Program was develo-ped primarily to place blood products on participatingDUSTOFF units for en route transfusion131. Although pri-marily a combat rescue and recovery platform, thePEDRO teams consist of two Emergency MedicalTechnician -Paramedic (EMT-P) trained pararescuemen(PJs)132. In addition to the EMT-B skills set, EMT-Ps canperform advanced airway maneuvers, needle decom-pression, cardiac monitoring, obtain IV with administra-tion of fluids and medications130. Medical crewmemberson a MERT include a physician (often an EmergencyRoom physician or an anesthesiologist), a critical carenurse, and two paramedics132. United States MarineCorps (USMC) rotary evacuation platforms are all des-ignated CASEVAC; no permanent MEDEVAC platformexists. Aircraft used for USMC CASEVAC are either diver-ted from a tactical mission or so designated as CASEVACfor specific missions. The designated CASEVAC aircraftare manned by Navy corpsmen who provide en routemedical care.

Improvements in survival have been attributed specifi-cally to altering the makeup of these teams from EMT-B-trained providers to critical-care trained mid-levelproviders and physicians132. Deployments of AirNational Guard MEDEVAC units staffed by flight medicstrained to civilian critical care flight paramedic (CCFP)standards afforded a comparison with standard MEDE-VAC. A retrospective review of severely injured patientsin Afghanistan demonstrated that estimated risk ofmortality decreased by 66% when aircrews evacuatedpatients with critical care flight paramedics (CCFPS) ins-tead of EMT-Bs 133. A similar study demonstrated signifi-cantly improved survival as well as improved parametersof shock in patients evacuated by CCFPs vs. EMT-Bs134.The demonstrable improved survival that CCFP-mannedMEDEVAC is able to offer has caused the US Army torecruit and train CCFPs to man its evacuation platforms.


VOL.90/1


Current recommendations for process improvement areto update flight medic training to EMT-Paramedic stan-dards133, 135. Furthering use of critical care-trainedrotary wing evacuation staff can be expected toimprove outcomes for critically ill war woundedpatients136.

Improved survival of battlefield casualties through thecourse of the U.S. military’s most recent conflicts hasalso been linked to shorter evacuation times mandatedby then Secretary of Defense Robert Gates in 2009. Hisdirective called for aeromedical transport times to beshorter than 60 minutes from point of injury to surgicalcare; these times were, on average, well over 60minutes prior to his mandate137. A report by Kotwaland associates demonstrated an increased survivalwhen comparing casualty evacuation times before andafter Mr. Gates’ mandate138. Secretary Gates’ 60 minutemandate provides a clear example of directed policyand its ability to improve care.

Military Trauma System

Robust civilian trauma systems exist in the United Statesand worldwide. A well-designed regional trauma systemwill coordinate training and rescue capabilities forpatients from the point of injury to definitive care andon to rehabilitation. The US military lacked a codifiedtrauma system during the initial phase of OEF. In 2004,the Joint Theatre Trauma System (JTTS) was implemen-ted in theater to establish a data registry and provide aperformance improvement capability for combat casual-ties. The Joint Trauma System (JTS) at the US ArmyInstitute of Surgical Research evolved from the JTTS toprovide an permanent support system for all DoDtrauma care. The system was tasked with improving thequality of care provided for combat wounded. Some ofthe JTS efforts included optimizing deployment of surgi-cal resources, informing the curriculum for training ofdeploying trauma teams, establishing worldwide com-munication about cases, and developing clinical practiceguidelines to ensure delivery of best practices139. Amongits most significant contributions, the JTS developed theDepartment of Defense Trauma Registry (DoDTR). Vastamounts of clinical data on injuries, treatments, andacute outcomes from nearly all combat casualties fromOEF/OIF are collected in the database. This data is alsoavailable to support research. DoDTR data analysis hel-ped develop and adapt CPGs that aided in improvingmortality in the combat wounded patient140. DoDTRdata will continue to guide current and future combatcasualty care141.

Prevention of Hypothermia

Hypothermia is a component of the ‘lethal triad’intrauma, which also includes coagulopathy and acidosis,and has been shown to correlate with severity ofinjury142. Its consequences include the following: coagu-lopathic bleeding, increased oxygen demand, acidosis,cold diuresis, vasoconstriction, and cardiac arrhyth-mias142, 143. Hypothermia has been shown to indepen-dently increase mortality in major trauma patients144

with mortality being twice that of normothermic

casualties. Prevention of hypothermia is therefore anecessity and has become a priority for the DoD combatcasualty care145, 146.

The JTS released a CPG to decrease rates of hypothermia.This was assessed upon arrival of patients at Role 3 faci-lities. Recommendations for prevention of hypothermiaare arranged by level of medical acuity. At point of injuryor Role I, the Hypothermia Prevention Management Kit(HPMK) is applied to package a patient and activelyrewarm them147. En route medical caregivers also mayhave disposable oral/cutaneous thermometers, warmedblankets, and hypothermia caps11. Role 2 and higherfacilities are able to provide warm operating rooms, for-ced air warming devices, and rapid fluid warmer/infu-sers148. After instituting this CPG149 the rates of hypo-thermic patients arriving at Role 3 facilities decreasedfrom seven-fold from 7% to 1%140.

Use of Tourniquets

Analysis of battlefield deaths determined that com-pressible extremity hemorrhage was a significant causeof potentially survivable death12. Tourniquets, whenplaced correctly, arrest arterial inflow to a hemorrha-ging extremity and prevent exsanguination. Thoughthe subject of renewed enthusiasm among the specialoperations community after their experience inSomalia, tourniquet use was not aggressively suppor-ted throughout the military at large in the first severalyears of OEF/OIF150. This reluctance to use tourniquetsearly and aggressively owed to historic concerns aboutthe effectiveness of tourniquets and the complicationsof failure, limb ischemia and nerve palsy151. Data fromthe late 1990s and early 2000s demonstrated the life-saving potential of tourniquets152, 153, 3% of deaths inthe early years of OEF/OIF could have been preventedwith extremity tourniquet placement5. In 2003, theAdvanced Technology Applications for CombatCasualty Care Conference was held in which subjectmatter experts discussed available evidence and recom-mended that all soldiers be issued tourniquets and trai-ned in their use150. The Surgeon General of the Armywould recommend in 2005 that all service membershad a tourniquet in their possession154. Tourniquetswere subsequently widely distributed to all deployedservice members and standardized into the individualfirst aid kit (IFAK)155. This policy of wide distribution oftourniquets accounted for an 85% decrease in deathsfrom extremity hemorrhage when compared between2001-2004 and after 20075.

Tourniquets are issued to all service members intendedto be self-applied or applied by either medical or non-medical colleagues. Tourniquets are placed on bleedingextremities 2-3 inches proximal to injury. Tourniquetsare tightened sufficiently to occlude significant hemor-rhage though some oozing from non-compressibleosseous medullary bleeding may continue150. Frequentreassessment of tourniquets is paramount throughoutthe evacuation process to ensure that they have notbecome dislodged or otherwise ineffective.

Proximal extremity injuries can cause hemorrhage that


VOL.90/1


is compressible but not amenable to tourniquet place-ment. Sites of potential junctional hemorrhage includethe neck, axillae, pelvis and perineum, gluteal region, andproximal inguinal region156. Commercial products havebeen developed which demonstrate the potential to pre-vent hemorrhage in groin injuries by occluding the com-mon femoral artery; these include the Abdominal andAortic Junctional Tourniquet (AAJT) (Compression Works,LLC), Combat Ready Clamp (CRoC) (Combat MedicalSystems, Charlotte NC), and Junctional EmergencyTreatment Tool (JETT) (North American Rescue, Greer,SC)157, 158. Data regarding effectiveness of these devices inthe field remains limited. Animal trials have suggestedthat junctional tourniquets provide effective hemostasisfor proximal hemorrhage. The CRoC was evaluated in aswine model of common femoral artery hemorrhage inwhich placement of the device provided hemostasis; sub-sequent removal of the device permitted exsanguina-tion159. Junctional tourniquets have been able to ceasesimulated femoral artery bleeding in a perfused cadavermodel157. Similarly, trials in healthy human volunteersdemonstrated cessation of lower extremity pulse afterdevice application which suggests efficacy of thesedevices160. Case reports from the field have demonstratedthat the devices are effective at stopping hemorrhage incombat161, 162.

Numerous prospective and retrospective studies attestto the performance of modern extremity tourniquets.A review of battlefield casualties among Israeli DefenseForce (IDF) soldiers from 1997-2001 demonstrated nodeaths from extremity hemorrhage in battlefieldcasualties treated with tourniquets152. A prospectivesurvey of combat casualties requiring tourniquet place-ment in Iraq in 2006 demonstrated a survival benefit aswell as low rate of complications secondary to tourni-quet use163. Retrospective review of casualties withtraumatic amputation, major extremity vascular injury,or pre-hospital placement of a tourniquet was perfor-med at a U.S. Combat Support Hospital (CSH) in Iraqwhich demonstrated that 57% of deaths without tour-niquet placement would likely have been prevented ifan appropriate tourniquet had been placed164.

Modern data about the benefits of tourniquet use hasbeen widely adopted. In a U.S. series looking at tourni-quet use in OEF/OIF, the rate of tourniquet placementfrom 2001-2010 increased from 4% to 40%165. The UKexperience in Iraq and Afghanistan from 2003-2007noted a dramatic increase in tourniquet utilization afterinclusion of tourniquet education in pre-deployment trai-ning and addition of tourniquets to individual first aidkits166. Rates of complications from tourniquet placement(neuropraxia, myonecrosis, extremity compartment syn-drome, thrombosis) have been shown to be low and out-weighed by the survival benefit of tourniquet place-ment167, 168. Tourniquets have been widely distributedamong service members in theatre and training inCombat Lifesaver and (CLS) and TCCC has been extensive.Use of tourniquets in civilian trauma patients has beenrecommended and has shown promising results169, 170.

The American College of Surgeons Committee on Trauma

(ACS-COT) recently held a meeting in Hartford, CT on theprevention of death from mass casualty and active shoo-ter situations. At this meeting, the Hartford Consensus IIIwas developed to define roles for responders and tech-niques of preventing death from hemorrhage171.Outgrowths of the Hartford Consensus included the“Stop the Bleed” campaign and the “B-Con” course.“Stop the Bleed” aims to educate and empower laypeo-ple to control life-threatening hemorrhage with directcompression and tourniquet172. The “B-Con” coursetrains laypeople in hemorrhage control with tourniquets,packing, and topical hemostatics173. Tragedies such as thebombing of the Boston Marathon in 2013 have shownthat hemorrhage control lessons learned in combat havebenefitted civilian victims174.

Prevention of Wound failure

Dismounted IED blasts yield large soft tissue defects. In theacute phase, these wounds are treated with serial debri-dement and irrigation followed by application of negativepressure wound therapy175. Definitive wound closure isachieved via delayed primary closure or use of tissue graf-ting. Traditionally the decision for wound closure was a cli-nical one based on the appearance of the wound in theoperating room, the patient’s clinical picture, and ultima-tely the surgeon’s judgment. Clean wounds in healthypatients typically heal; however, adiposity, poor nutrition,infection or colonization, tobacco use, and immunosup-pressed states all decrease the likelihood of normal woundhealing. Failed or ‘dehiscent’wounds do not undergo thenormal coagulative, inflammatory, proliferative, andremodeling stages of wound healing176. Dehiscent woundswill demonstrate separation of the wound edges and maysuppurate. Without intervention, dehiscent wounds willgo on to become at best chronic non-healing wounds andat worst grossly infected wounds that endanger the life ofthe patient. Even with ideal conditions, well-appearingwounds in stable patients were at risk of dehiscence andless-reassuring appearing wounds may be capable of beingsuccessfully closed177. Rates of wound failure in OEF/OIFwere reported to be 16-27%68. Significant work has beenexpended attempting to better determine which factorswill ultimately favor successful wound closure anddecrease the likelihood of wound dehiscence.

The Surgical Critical Care Initiative (SC2i) has utilizedwound effluent, blood samples, and tissue cultures toclassify the wound microenvironment and systemicwound environment favoring successful wound closure7.Wound effluent from wounds that went on to dehisceexpressed higher IL-6, IL-1α, IL-1β, IL-3, EGF, bFGF andlower IL-2, IL-4, MCP-1, MIG and IP-107, 178. Elevations ofIL-1α, IL-1β, IL-8, MCP-1, MIP-1, GM-CSF and depressionsof IL-4, IL-5, IL-13 in wound tissue biopsies were associa-ted with an increased likelihood of dehiscence7, 178.Forsberg and colleagues found that increased serum andwound effluent procalcitonin as well as decreasedwound effluent RANTES protein level and IL-13 level inextremity war wounds were shown separately toincrease the likelihood of wound dehiscence177.Conversely, no wound dehiscence was observed in thepresence of normal wound effluent procalcitonin, IL-13,


VOL.90/1


or RANTES. The ability to more accurately predict whe-ther or not wounds are ready for definitive closure willlikely decrease hospital stay and decrease the likelihoodof wound dehiscence and/or amputation revision.

Predicting the Need for Massive Transfusion

Blood bank management is challenging in an austereenvironment, owing to the difficulties of supply chain,appropriate storage, and proper utilization179. “Buddyblood,” or warm whole blood donated from friendly ele-ments is often used for trauma resuscitation amongNATO troops180, 181. Small forward operating bases withRole II medical facilities often experienced long periodsof calm punctuated by mass casualty (MASCAL) incidents.Long-term storage of large quantities of blood productsis logistically difficult at small facilities, resulting in thepotential for significant waste182.

Certain injury patterns increase the likelihood of theneed for massive transfusion. Benfield and colleaguesdemonstrated that in dismounted IED blast casualtieswith multiple traumatic limb amputations the followinginjuries were all independent predictors for necessita-ting massive transfusion: open pelvic fractures, glu-teal/perineal soft tissue injuries, and gastrointestinalinjuries. In addition, the authors found that casualtieswith these injuries required 50-100% more blood pro-ducts than those who did not sustain these injuries6. Asan adjunct to the surgeon’s clinical judgment, severaltools are available to help predict the need for massivetransfusion in trauma183, 184, 185. These include theTrauma-Associated Severe Hemorrhage scoring toolwhich uses systolic blood pressure, hemoglobin, the pre-sence of intra-abdominal fluid, complex long boneand/or pelvic fractures, tachycardia, acid/base status(base excess), and gender186. In the case of the TASHtool, Hb is the most substantial contributor to predictionmodel186.

Interestingly, Benfield found that admission hemoglobin(Hb) was not a significant predictor of the need fortransfusion. In the past, time between injury and stabili-zation/resuscitation in trauma had been significant andaggressive crystalloid fluid resuscitation had been initia-ted en route to definitive care. This allowed the Hb todecrease in a manner consistent with the actually oxy-gen-carrying content of the blood. Now, modern combatcasualties are rapidly transported to a forward surgicalasset typically in a permissively hypotensive state inaccordance with damage control resuscitation principles.This limits the utility of Hb as a predictor for transfusionby allowing it to remain falsely elevated; failing toreflect the reality of the physiologic derangements in apatient in hemorrhagic shock6. Further research is nee-ded to adequately guide steerage of blood productresources for optimal distribution in time of need.

Factors such as systolic blood pressure < 110mmHg, heartrate > 105 beats per minute, hematocrit < 32%, as well aspH < 7.25 were used to help guide decision-making aboutthe need for MT187, 188. More recent findings have dispu-ted admission hemoglobin and hematocrit as predictors

of MT, finding instead that open pelvic fractures, gas-trointestinal injuries, and/or extensive perineal or glutealwounds suggested the needed for MT. In that study,admission Hb and ISS were not found to affect the needfor MT6.

The difficulty in precisely determining indicators of mas-sive transfusion from single variables led several traumasurgeons to develop a machine learning-clinical decisionsupport tool189. This tool takes into account severalhemodynamic parameters (blood pressure, heart rate,and base deficient) as well as mechanism of injury andadjusts weight given to specific variables based oncontinued data input189. The authors went on to deve-lop a smartphone application to improve ease of useand speed of decision-making in a clinical setting. Morework is needed to discover ideal indicators for traumapatients that should receive MT.

Balanced Resuscitation (DCR)

Data from OEF and OIF has had a significant impact onthe practice of blood and fluid resuscitation in trauma11.Massive transfusion (MT) refers to transfusion of 10 orgreater units of packed red blood cells or whole blood ina 24 hour period. MT acts as a proxy for the most grie-vously injured patients. Traditional practice patterns calledfor aggressive crystalloid resuscitation to replete the intra-vascular space and blood-component based blood pro-duct resuscitation in major trauma190. Blood productresuscitation ratios were not fixed; patients would receivesignificantly more packed red blood cells than FFP or pla-telets191. It was hypothesized that outcomes in majortrauma patients would be improved by increasing syste-mic oxygen delivery above normal with aggressive fluids;however, this was shown not to be the case192, 193. Earlydata in OEF/OIF suggested that hypotensive resuscitationand balanced use of blood components improved survi-val191. After issuance of the DCR CPG, patients requiringMT received blood products in a ratio of 1: 1: 1 (packedred blood cells: plasma: platelets) or fresh whole blood(FWB) along with cryoprecipitate as indicated to reversecoagulopathy and acidosis180, 194, 195. Banked blood istransfused during a massive transfusion in a “last-in/first-out” pattern to ensure that critically injured patient canderive the most benefit from transfusion196. Rapid andfrequent shipping of blood products to theater hasdecreased the average age products given during a mas-sive transfusion from 33 days to 23 days182. A goal of nottransfusing blood products older than 14 days has beenproposed but reaching this goal has been difficult toachieve182, 197. Review of the DoDTR suggests that morta-lity among massively transfused casualties decreased from32% to 20% during the time course following adoptionof the MT CPG140. Studies assessing damage control resus-citation in civilian institutions have also demonstrated sur-vival benefits198, 199. Consequently civilian trauma institu-tions have begun modifying massive transfusion practicesto better approximate 1: 1: 1 resuscitation200.

Biomarker Profile Analysis

The wound microenvironment and patient serum in blasttrauma can yield practical data about the likelihood of


VOL.90/1


wound dehiscence, invasive fungal infection, and theinterval development of heterotopic ossification7, 98, 102, 178.Analysis of wound effluent and serum markers in servicemembers with traumatic bilateral lower extremity amputa-tions from blast trauma was performed in a study by Lisboaet al. The findings were consistent with previous assess-ments that IL-8 was relatively increased in trauma patients;IL-13 and GM-CSF were relatively decreased201, 202. De novofindings from this study demonstrated increased IL-1 anddecreased MCP-1 and MIG in patients with bilateral lowerextremity amputations that went on to suffer a wounddehiscence as well as increased IL-1RA, IL-4, IL-8, IL-8, MIG,MIP-1a, and MIP-1b in patients with the same injury patternthat went on to develop heterotopic ossification7. Of parti-cular interest is the finding that patients that would subse-quently develop wound dehiscence could be characterizedby a local cytokine-predominant immune response incontrast to a predominantly systemic immune responseseen in those that would go on to develop heterotopic ossi-fication7. In a recent paper by Forsberg and colleagues,serum and wound biomarkers from military blast traumapatients were compared with those of civilian blunt traumapatients. The researchers demonstrated that similar altera-tions of biomarker profiles and rates of wound dehiscencewere noted between these two study populations. Datafrom this study permitted development of a clinical deci-sion support tool using biomarker data to predict the like-lihood of wound dehiscence203. Research is ongoing utili-zing wound microenvironment and serum biomarkers tofurther explore the immune response to trauma.

Lack of utility of ISS

The Injury Severity Score (ISS)204 may be a poor gaugeof injuries in combat trauma patients. ISS has beendemonstrated to underestimate injury severity as wellas resource utilization including transfusion require-ments, length of ICU stay, and length of hospital stay inpatients with extremity amputations205. The ISS andwas developed through data from civilian motor vehi-cle injuries204. The ISS is calculated first by computing ascore on the Abbreviated Injury Scale (AIS)206. AISscores are calculated by determining a numerical seve-rity of injury from 0 (no injury) to 6 (nonsurvivable) for6 body regions. These body regions are Head & Neck,Face, Chest, Abdomen, Extremity, and External. ISS iscalculating by squaring the top three highest scoredbody regions and adding them together. The maximumscore is 75; a score of 6 in any body region automati-cally scores 75. A patient with severe bilateral lowerextremity injuries and a patient with a severe unilaterallower extremity injury would be scored the same in theExtremity body region. This represents a flaw in the ISSscoring system as several studies have demonstratedthat these patients may have remarkably differentcourses of illness and resource requirements9, 207.However, the ISS may be of some utility in comparingand contrasting between severities of injury betweenpatients with similar mechanisms of injury. To addressthe shortcomings of the ISS scale, new assessments ofinjury severity have been proposed. These scales ofteneschew civilian models based off motor vehicle traumaand utilizing models more consistent with combat

trauma such as Military Combat Injury Scale (MCIS)207.New injury scales continue to be developed to betterdescribe injury patterns and true physiologic insult inwar wounds, but these scales need validation.

Novel Injury Scales

New nomenclature was developed to accurately des-cribe lower extremity injuries caused by IEDs, where theuse of previous systems such as the Gustillo andMangled Extremity Severity Score failed to provide suf-ficient detail. The Bastion Classification14 was proposedas a way to grade the proximal extent of lower extre-mity IED injury in order to improve communication bet-ween physicians at various echelons of care and to helpguide treatment especially in regards to vascularcontrol. According to the Bastion Classification, Level 1injuries extend no further proximally than the foot allo-wing for below-knee tourniquet placement. Level 2injuries involve the lower leg but are be amenable tobelow-knee tourniquet placement. Level 3 injuriesinvolve lower leg and/or thigh and can accommodatetourniquet placement above the knee. Level 4 injuriesinvolve the proximal thigh where tourniquet placementwould be ineffective or technically challenging to place.Level 5 injuries extend to the level of the buttock14.While this classification system was internally validatedand provides more information regarding the extent ofinjury, its widespread use was not implemented andoperative management decisions still remain guided bythe surgeon’s clinical judgment208.

Pelvic and perineal injuries incurred by blasts were alsocategorized. The pelvi-perineal trauma score (PPTS) divi-ded the pelvis and perineum into anterior (urogenital),middle (perineal), and posterior (anorectal) zones209.Injuries to structures in these zones were then scored byseverity to calculate a score from 1-36. Presence of a pel-vic fracture and its subsequent classification increasedthe potential range from 1-42209. Mortality was shownto increase with increasing PPTS and therefore PPTSmay be useful for predicting mortality after pelvic andperineal blast wounds209.

Evolving Practice with REBOA utilization

As mentioned previously, REBOA is emerging as a use-ful adjunct for temporary hemorrhage control prior todefinitive management. Though previously shunnedfor high rates of complications and death, new tech-niques and equipment have renewed interest in itsuse210, 211. REBOA is intended as a less-invasive alterna-tive to resuscitative thoracotomy (RT) or as an adjunctin RT212. REBOA attenuates hemorrhage through occlu-sion of the aorta via endovascular balloon. Indicationsfor REBOA include pulseless electrical activity or pro-found shock in the setting of blunt or penetratingtrauma yielding intra-abdominal, pelvic, or hemorrha-ging extremity injuries211. The promising data from civi-lian centers utilizing aortic balloon occlusion in traumahas led to the addition of the REBOA to the militaryCPGs. The REBOA CPG recommends that REBOA only beperformed at surgically capable facilities in patientswith shock due to uncontrolled chest, abdomen, or

VOL.90/1



extremity hemorrhage213. To date, there have been afew reports of U.S. military providers using this devicein theaters of combat operations.

Current placement requires fluoroscopic guidance toconfirm guidewire and balloon placement. This is alimitation in facilities where fluoroscopy may not bereadily available. More recent iterations of REBOAdevices have been developed that may allow safe bal-loon placement without imaging such as the ER-REBOA(Pryor Medical Devices, Boerne, TX) Non-fluoroscopicREBOA placement has been shown to be feasible in aswine model of hemorrhagic shock214. The FederalDrug Administration (FDA) recently approved a non-fluoroscopic REBOA device for use in US civilian hospi-tals. In the UK, pre-hospital placement of a REBOAwithout fluoroscopy was successfully performed by aphysician with London Air Ambulance215. These newerdevices may allow physicians or special operationsmedics and corpsmen to place REBOA in the pre-hospi-tal environment. The CPG already recommends REBOAplacement by anatomic landmarks if fluoroscopic sup-port is not available. A measurement taken from thefemoral head to a point halfway between the 12th riband the medial heads of the clavicles should approxi-mate the necessary depth for guidewire advancementto the distal aortic arch213. Moving forward, militaryproviders will need proper training on this device priorto deployment to ensure appropriate technical perfor-mance and maximal benefit to the casualty. Training inREBOA insertion technique is currently offered to sur-geons through the Basic Endovascular Skills for Trauma(BEST) course.

Use of Tranexamic Acid

Tranexamic acid (TXA) is a synthetic analog of theamino acid lysine216. TXA indirectly prevents fibrinoly-sis; leading to its initial applications in preventing obs-tetric and coagulopathic bleeding217. TXA is an adjunc-tive therapy recommended to be given within 3 hoursof injury in a patient thought likely to require massivetransfusion. Patients in hemorrhagic shock, patientswith 1 or more proximal amputations, or patients withpenetrating torso injuries are more likely to requireMT6, 125. Providers can administer TXA as soon as intra-venous or intraosseous access is obtained. The founda-tion for the use of TXA in trauma is based on two stu-dies, the CRASH-2 and MATTERs trial. The CRASH-2trial was a large civilian multi-center study thatdemonstrated a survival advantage in trauma patientsreceiving TXA versus those that did not. Post-hoc ana-lysis revealed that administration of TXA should begiven within three hours of injury and ideally withinthe first hour. The subsequent MATTERs study was aretrospective study of the military application of TXAwhich also demonstrated a mortality benefit in casual-ties receiving TXA without an increase in adverseevents218, 219. Interestingly, in both studies there wasno difference in blood product transfusion require-ments between treatment groups, which has raisedquestions into the mechanism of action of TXA outsideof its anti-fibrinolytic properties. In cardiac patients

administration of TXA has been shown to have ananti-inflammatory function that may attenuate theimmune response after cardiac bypass220, 221.Additional research is needed to better define themechanism by which TXA improves survival.

SUMMARY

Comprehensive data regarding injury patterns, mana-gement, and outcomes of battlefield trauma wasgathered throughout OIF and OEF. This data has beenand continues to be analyzed to guide trauma practicesfor both military and civilian trauma care in the future.The promising results from the utilization of TCCC,DCR, and the other military CPGs will likely continue tobe exploited in the next conflict.

Forward military medical assets are often resource-scarce in terms of space and supplies. Predictingresource utilization is of critical logistical importance insupplying materiel to environments such as Role II andRole III facilities. This is compounded by the potentialfor normal operating tempo to be stressed by the addi-tion of a mass casualty (MASCAL) incident. Predictivemodels that allow for better planning for neededresources will be of benefit in future conflicts.

Ongoing basic science and translational research conti-nues to answer questions about the topics raisedabove. Animal models of HO, VTE, polytrauma with thefocus on the immune response, and invasive fungalinfections provide novel strategies for intervention.Furthermore, advances in prosthetic devices and reha-bilitation programs have led to better functional out-comes for these combat amputees.

Further investigation of data obtained in the DoDTRwill continue to improve upon current practice whilealso providing innovative approaches to trauma care.As the utilization of IEDs by foreign militaries and othernon-state actors increases, the knowledge and expe-rience gained over the past fifeteen years of conflictwill assuredly save life and limb.

ABSTRACT

Improvised explosive devices (IEDs) have caused signifi-cant morbidity and mortality in Iraq and Afghanistan.High-yield IED injury patterns produced critically illpatients that have challenged military medical care.Studies of both original research and reviews from theUS and British military experience during these twowars were explored.

Dismounted complex blast injury (DCBI) is a pattern ofinjuries sustained by dismounted service members.DCBI is a unilateral or bilateral proximal traumaticlower extremity amputation with accompanying softtissue injuries to the pelvis, perineum, and glutealregion1. More severe iterations include abdominal hol-low viscus and solid organ injuries as well as complexupper extremity injuries2. The DCBI pattern increased infrequency throughout Operation Enduring Freedom


VOL.90/1


extremity hemorrhage213. To date, there have been afew reports of U.S. military providers using this devicein theaters of combat operations.

Current placement requires fluoroscopic guidance toconfirm guidewire and balloon placement. This is alimitation in facilities where fluoroscopy may not bereadily available. More recent iterations of REBOAdevices have been developed that may allow safe bal-loon placement without imaging such as the ER-REBOA(Pryor Medical Devices, Boerne, TX) Non-fluoroscopicREBOA placement has been shown to be feasible in aswine model of hemorrhagic shock214. The FederalDrug Administration (FDA) recently approved a non-fluoroscopic REBOA device for use in US civilian hospi-tals. In the UK, pre-hospital placement of a REBOAwithout fluoroscopy was successfully performed by aphysician with London Air Ambulance215. These newerdevices may allow physicians or special operationsmedics and corpsmen to place REBOA in the pre-hospi-tal environment. The CPG already recommends REBOAplacement by anatomic landmarks if fluoroscopic sup-port is not available. A measurement taken from thefemoral head to a point halfway between the 12th riband the medial heads of the clavicles should approxi-mate the necessary depth for guidewire advancementto the distal aortic arch213. Moving forward, militaryproviders will need proper training on this device priorto deployment to ensure appropriate technical perfor-mance and maximal benefit to the casualty. Training inREBOA insertion technique is currently offered to sur-geons through the Basic Endovascular Skills for Trauma(BEST) course.

Use of Tranexamic Acid

Tranexamic acid (TXA) is a synthetic analog of theamino acid lysine216. TXA indirectly prevents fibrinoly-sis; leading to its initial applications in preventing obs-tetric and coagulopathic bleeding217. TXA is an adjunc-tive therapy recommended to be given within 3 hoursof injury in a patient thought likely to require massivetransfusion. Patients in hemorrhagic shock, patientswith 1 or more proximal amputations, or patients withpenetrating torso injuries are more likely to requireMT6, 125. Providers can administer TXA as soon as intra-venous or intraosseous access is obtained. The founda-tion for the use of TXA in trauma is based on two stu-dies, the CRASH-2 and MATTERs trial. The CRASH-2trial was a large civilian multi-center study thatdemonstrated a survival advantage in trauma patientsreceiving TXA versus those that did not. Post-hoc ana-lysis revealed that administration of TXA should begiven within three hours of injury and ideally withinthe first hour. The subsequent MATTERs study was aretrospective study of the military application of TXAwhich also demonstrated a mortality benefit in casual-ties receiving TXA without an increase in adverseevents218, 219. Interestingly, in both studies there wasno difference in blood product transfusion require-ments between treatment groups, which has raisedquestions into the mechanism of action of TXA outsideof its anti-fibrinolytic properties. In cardiac patients

administration of TXA has been shown to have ananti-inflammatory function that may attenuate theimmune response after cardiac bypass220, 221.Additional research is needed to better define themechanism by which TXA improves survival.

SUMMARY

Comprehensive data regarding injury patterns, mana-gement, and outcomes of battlefield trauma wasgathered throughout OIF and OEF. This data has beenand continues to be analyzed to guide trauma practicesfor both military and civilian trauma care in the future.The promising results from the utilization of TCCC,DCR, and the other military CPGs will likely continue tobe exploited in the next conflict.

Forward military medical assets are often resource-scarce in terms of space and supplies. Predictingresource utilization is of critical logistical importance insupplying materiel to environments such as Role II andRole III facilities. This is compounded by the potentialfor normal operating tempo to be stressed by the addi-tion of a mass casualty (MASCAL) incident. Predictivemodels that allow for better planning for neededresources will be of benefit in future conflicts.

Ongoing basic science and translational research conti-nues to answer questions about the topics raisedabove. Animal models of HO, VTE, polytrauma with thefocus on the immune response, and invasive fungalinfections provide novel strategies for intervention.Furthermore, advances in prosthetic devices and reha-bilitation programs have led to better functional out-comes for these combat amputees.

Further investigation of data obtained in the DoDTRwill continue to improve upon current practice whilealso providing innovative approaches to trauma care.As the utilization of IEDs by foreign militaries and othernon-state actors increases, the knowledge and expe-rience gained over the past fifeteen years of conflictwill assuredly save life and limb.

ABSTRACT

Improvised explosive devices (IEDs) have caused signifi-cant morbidity and mortality in Iraq and Afghanistan.High-yield IED injury patterns produced critically illpatients that have challenged military medical care.Studies of both original research and reviews from theUS and British military experience during these twowars were explored.

Dismounted complex blast injury (DCBI) is a pattern ofinjuries sustained by dismounted service members.DCBI is a unilateral or bilateral proximal traumaticlower extremity amputation with accompanying softtissue injuries to the pelvis, perineum, and glutealregion1. More severe iterations include abdominal hol-low viscus and solid organ injuries as well as complexupper extremity injuries2. The DCBI pattern increased infrequency throughout Operation Enduring Freedom


VOL.90/1


(OEF) and Operation Iraq Freedom (OIF), emphasizingthe need for familiarity with treatment1,3.

The care of the wounded service member sustainingDCBI evolved with the application of Tactical CombatCasualty Care (TCCC), rapid evacuation to NATO Role IIand III surgical facilities, and enhanced en route carecapabilities4, 5. Index surgical procedures were brief andfocused; and non-life or limb-saving interventions werepostponed until the critically ill patient condition wasstabilized6.

The complex dismounted IED blast injury pattern hasbeen found to be associated with major complicationsincluding wound dehiscence, invasive fungal infection,venous thromboembolism, heterotopic ossification, anddeath. Wound dehiscence has been demonstrated to beassociated with a distinct local and systemic cytokine pro-file at the time of wound closure7. Predictive modelsincluding a clinical decision support tool for identifyingrisk of Invasive Fungal Infection (IFI) have been develo-ped to assist the surgeon in wound management. Theprevalence of venous thromboembolism among combatinjured exceeds that seen in the civil trauma patientpopulation despite VTE chemoprophylaxis8. Strict adhe-rence to VTE prophylaxis has decreased VTE rates in thecombat injured population8. The mortality of DCBIranges from 8-10%1, 9. Outcomes from this injury patternhave been improved by evidence- and experienced-basedbest practices, prevention, training, and advancements inrehabilitation10, 11.

REFERENCES

11. DCBI, Dismounted Complex Blast Injury: Report of theArmy Dismounted Complex Blast Injury Task Force. 2011:Fort Sam Houston, TX.

12. ANDERSEN, R.C., et al., Dismounted Complex Blast Injury.J Surg Orthop Adv, 2012. 21 (1): p. 2-7.

13. SCHOENFELD, A.J., et al., The nature and extent of warinjuries sustained by combat specialty personnel killedand wounded in Afghanistan and Iraq, 2003-2011. JTrauma Acute Care Surg, 2013. 75 (2): p. 287-91.

14. BUTLER, F.K., Jr., et al., Tactical combat casualty care 2007:evolving concepts and battlefield experience. Mil Med,2007. 172 (11 Suppl): p. 1-19.

15. EASTRIDGE, B.J., et al., Death on the battlefield (2001-2011): implications for the future of combat casualty care.J Trauma Acute Care Surg, 2012. 73 (6 Suppl 5): p. S431-7.

16. BENFIELD, R.J., et al., Initial predictors associated withoutcome in injured multiple traumatic limb amputations:a Kandahar-based combat hospital experience. Injury,2012. 43 (10): p. 1753-8.

17. LISBOA, F.A., et al., Bilateral lower-extremity amputationwounds are associated with distinct local and systemiccytokine response. Surgery, 2013. 154 (2): p. 282-90.

18. HOLLEY, A.B., et al., Thromboprophylaxis and VTE rates insoldiers wounded in Operation Enduring Freedom andOperation Iraqi Freedom. Chest, 2013. 144 (3): p. 966-73.

19. FLEMING, M., et al., Dismounted complex blast injuries:patterns of injuries and resource utilization associatedwith the multiple extremity amputee. J Surg Orthop Adv,2012. 21 (1): p. 32-7.

10. KOTWAL, R.S., et al., Eliminating preventable death onthe battlefield. Arch Surg, 2011. 146 (12): p. 1350-8.

11. PALM, K., et al., Evaluation of military trauma systempractices related to damage-control resuscitation. JTrauma Acute Care Surg, 2012. 73 (6 Suppl 5): p. S459-64.

12. KELLY, J.F., et al., Injury severity and causes of death fromOperation Iraqi Freedom and Operation EnduringFreedom: 2003-2004 versus 2006. J Trauma, 2008. 64 (2Suppl): p. S21-6; discussion S26-7.

13. BELMONT, P.J., A.J. SCHOENFELD, AND G. GOODMAN,Epidemiology of combat wounds in Operation IraqiFreedom and Operation Enduring Freedom: orthopaedicburden of disease. J Surg Orthop Adv, 2010. 19 (1): p. 2-7.

14. JACOBS, N., et al., Lower limb injuries caused by improvi-sed explosive devices: proposed 'Bastion classification'and prospective validation. Injury, 2014. 45 (9): p. 1422-8.

15. CHAMPION, H.R., J.B. HOLCOMB, and L.A. YOUNG,Injuries from explosions: physics, biophysics, pathology,and required research focus. J Trauma, 2009. 66 (5): p.1468-77; discussion 1477.

16. USD (AT&L), DoDD 6025.21E: Medical Research forPrevention, Mitigation, and Treatment of Blast Injuries,D.o. Defense, Editor. 2006.

17. MAMCZAK, C.N. and E.A. ELSTER, Complex dismounted IEDblast injuries: the initial management of bilateral lowerextremity amputations with and without pelvic and perinealinvolvement. J Surg Orthop Adv, 2012. 21 (1): p. 8-14.

18. RAMASAMY, A., et al., Injuries from roadside improvisedexplosive devices. J Trauma, 2008. 65 (4): p. 910-4.

19. RAMASAMY, A., A.M. HILL, and J.C. CLASPER, Improvisedexplosive devices: pathophysiology, injury profiles andcurrent medical management. J R Army Med Corps, 2009.155 (4): p. 265-72.

20. RAMASAMY, A., et al., Outcomes of IED foot and ankleblast injuries. J Bone Joint Surg Am, 2013. 95 (5): p. e25.

21. Penn-Barwell, J.G., et al., Acute bilateral leg amputationfollowing combat injury in UK servicemen. Injury, 2014. 45(7): p. 1105-10.

22. STANSBURY, L.G., et al., Amputations in U.S. military per-sonnel in the current conflicts in Afghanistan and Iraq. JOrthop Trauma, 2008. 22 (1): p. 43-6.

23. TONG, D. and R. BEIRNE, Combat body armor and injuriesto the head, face, and neck region: a systematic review.Mil Med, 2013. 178 (4): p. 421-6.

24. BELMONT, P.J., Jr., et al., Combat wounds in Iraq andAfghanistan from 2005 to 2009. J Trauma Acute CareSurg, 2012. 73 (1): p. 3-12.

25. COMSTOCK, S., et al., Spinal injuries after improvisedexplosive device incidents: implications for Tactical CombatCasualty Care. J Trauma, 2011. 71 (5 Suppl 1): p. S413-7.

VOL.90/1



26. BUTLER, F.K., Jr., Tactical medicine training for SEAL mis-sion commanders. Mil Med, 2001. 166 (7): p. 625-31.

27. POLK, T.M., et al., Successful integration of military tacti-cal requirements into a civilian training paradigm:Advanced Trauma Life Support - Operational Emphasis(ATLS-OE). Journal of the American College of Surgeons.221 (4): p. e76.

28. SHACKELFORD, S.A., et al., Prehospital pain medicationuse by U.S. Forces in Afghanistan. Mil Med, 2015. 180 (3):p. 304-9.

29. JANSEN, J.O., et al., Early management of proximal trau-matic lower extremity amputation and pelvic injury cau-sed by improvised explosive devices (IEDs), in Injury. 2012:Netherlands. p. 976-9.

30. MITCHELL, T.A., et al., An 8-year review of operationenduring freedom and operation iraqi freedom resuscita-tive thoracotomies. Mil Med, 2015. 180 (3 Suppl): p. 33-6.

31. BURLEW, C.C., et al., Western Trauma Association criticaldecisions in trauma: resuscitative thoracotomy. J TraumaAcute Care Surg, 2012. 73 (6): p. 1359-63.

32. JTTS, Emergency Resuscitative Thoracotomy. 2012, JointTheatre Trauma System: San Antonio, TX.

33. EDENS, J.W., et al., Longterm outcomes after combatcasualty emergency department thoracotomy. J Am CollSurg, 2009. 209 (2): p. 188-97.

34. MORRISON, J.J., et al., Resuscitative endovascular balloonocclusion of the aorta: a gap analysis of severely injuredUK combat casualties. Shock, 2014. 41 (5): p. 388-93.

35. JTTS, Resuscitative Endovascular Balloon Occlusion of theAorta (REBOA) for Hemorrhagic Shock. 2014.

36. Morrison, J.J., et al., Aortic balloon occlusion is effective incontrolling pelvic hemorrhage. J Surg Res, 2012. 177 (2): p.341-7.

37. ELSTER, E., Forward Deployed Experience, M. Bradley,Editor. 2015: Bethesda, MD.

38. JTTS, Management of High Bilateral Amputations. 2012:San Antonio, TX.

39. WALL, M.J., et al., Open and Endovascular Approaches toAortic Trauma, in Tex Heart Inst J. 2010. p. 675-7.

40. STARNES, B.W., et al., Extremity vascular injuries on thebattlefield: tips for surgeons deploying to war. J Trauma,2006. 60 (2): p. 432-42.

41. JTTS, Wartime Vascular Injury. 2012: San Antonio, TX.

42. CLOUSE, W.D., et al., In-theater management of vascularinjury: 2 years of the Balad Vascular Registry. J Am CollSurg, 2007. 204 (4): p. 625-32.

43. FOX, C.J. and B.W. STARNES, Vascular surgery on the modernbattlefield. Surg Clin North Am, 2007. 87 (5): p. 1193-211, xi.

44. FELICIANO, D.V., Management of traumatic retroperito-neal hematoma. Ann Surg, 1990. 211 (2): p. 109-23.

45. RASMUSSEN, T.E., et al., The use of temporary vascular

shunts as a damage control adjunct in the managementof wartime vascular injury. J Trauma, 2006. 61 (1): p. 8-12;discussion 12-5.

46. CLOUSE, W.D., et al., Upper extremity vascular injury: acurrent in-theater wartime report from Operation IraqiFreedom. Ann Vasc Surg, 2006. 20 (4): p. 429-34.

47. FOX, C.J., et al., Contemporary management of wartimevascular trauma. J Vasc Surg, 2005. 41 (4): p. 638-44.

48. CROSS, A.M., et al., The incidence of pelvic fractures withtraumatic lower limb amputation in modern warfare dueto improvised explosive devices. J R Nav Med Serv, 2014.100 (2): p. 152-6.

49. COTHREN, C.C., et al., Preperitonal pelvic packing forhemodynamically unstable pelvic fractures: a paradigmshift. J Trauma, 2007. 62 (4): p. 834-9; discussion 839-42.

50. LEE, C. and K. PORTER, The prehospital management ofpelvic fractures. Emerg Med J, 2007. 24 (2): p. 130-3.

51. GHANAYEM, A.J., et al., Emergent treatment of pelvicfractures. Comparison of methods for stabilization. ClinOrthop Relat Res, 1995 (318): p. 75-80.

52. GHANAYEM, A.J., et al., The effect of laparotomy andexternal fixator stabilization on pelvic volume in an uns-table pelvic injury. J Trauma, 1995. 38 (3): p. 396-400; dis-cussion 400-1.

53. TONETTI, J., Management of recent unstable fractures ofthe pelvic ring. An update conference supported by theClub Bassin Cotyle. (Pelvis-Acetabulum Club). OrthopTraumatol Surg Res, 2013. 99 (1 Suppl): p. S77-86.

54. JTTS, Pelvic Fracture Care, J.T.T. System, Editor. 2012: SanAntonio, TX.

55. LI, Q., et al., Retroperitoneal packing or angioemboliza-tion for haemorrhage control of pelvic fractures-Quasi-randomized clinical trial of 56 haemodynamically unsta-ble patients with Injury Severity Score >/=33. Injury, 2015.

56. RAMASAMY, A., et al., The open blast pelvis: the signifi-cant burden of management. J Bone Joint Surg Br, 2012.94 (6): p. 829-35.

57. DuBOSE, J., et al., Bilateral internal iliac artery ligation asa damage control approach in massive retroperitonealbleeding after pelvic fracture. J Trauma, 2010. 69 (6): p.1507-14.

58. DUNCAN, J.E., et al., Management of colorectal injuriesduring operation iraqi freedom: patterns of stoma usage.J Trauma, 2008. 64 (4): p. 1043-7.

59. O’DONNELL, M.T., et al., Diversion remains the standardof care for modern management of war-related rectalinjuries. Mil Med, 2014. 179 (7): p. 778-82.

60. GLASGOW, S.C., et al., Initial management and outcomeof modern battlefield anal trauma. Dis Colon Rectum,2014. 57 (8): p. 1012-8.

61. MOSSADEGH, S., et al., Improvised explosive device rela-ted pelvi-perineal trauma: anatomic injuries and surgicalmanagement. J Trauma Acute Care Surg, 2012. 73 (2 Suppl 1):p. S24-31.

40International Review of the Armed Forces Medical Service Revue Internationale des Services de Santé des Forces Armées

VOL.90/1


62. VAN WESSEM, K.J., et al., Selective faecal diversion inopen pelvic fractures: reassessment based on recent expe-rience. Injury, 2012. 43 (4): p. 522-5.

63. VELMAHOS, G.C., et al., Early closure of colostomies intrauma patients--a prospective randomized trial. Surgery,1995. 118 (5): p. 815-20.

64. LEININGER, B.E., et al., Experience with wound VAC anddelayed primary closure of contaminated soft tissue inju-ries in Iraq. J Trauma, 2006. 61 (5): p. 1207-11.

65. JTTS, Initial Management of War Wounds: WoundDebridement and Irrigation. 2012: San Antonio, TX.

66. MACHEN, S., Management of traumatic war woundsusing vacuum-assisted closure dressings in an austereenvironment. US Army Med Dep J, 2007: p. 17-23.

67. SCHLATTERER, D. and K. HIRSHORN, Negative pressurewound therapy with reticulated open cell foam-adjunc-tive treatment in the management of traumatic woundsof the leg: a review of the literature. J Orthop Trauma,2008. 22 (10 Suppl): p. S152-60.

68. FORSBERG, J.A., et al., Do inflammatory markers portendheterotopic ossification and wound failure in combatwounds? Clin Orthop Relat Res, 2014. 472 (9): p. 2845-54.

69. MORLEY, M.G., et al., Blast eye injuries: a review for firstresponders. Disaster Med Public Health Prep, 2010. 4 (2):p. 154-60.

70. MAZZOLI, R.A., K.R. GROSS, and F.K. BUTLER, The use ofrigid eye shields (Fox shields) at the point of injury forocular trauma in Afghanistan. J Trauma Acute Care Surg,2014. 77 (3 Suppl 2): p. S156-62.

71. JTTS, Initial Care of Ocular and Adnexal Injuries by Non-Ophthalmologists at Role 1, Role 2, and Non-OphthalmicRole 3 Facilities. 2014: San Antonio, TX.

72. BUMBASIREVIC, M., et al., Current management of themangled upper extremity. Int Orthop, 2012. 36 (11): p.2189-95.

73. KUMAR, A.R., et al., Lessons from the modern battlefield:successful upper extremity injury reconstruction in thesubacute period. J Trauma, 2009. 67 (4): p. 752-7.

74. ANDERSEN, R.C., et al., Extremity War Injuries VIII: seque-lae of combat injuries. J Am Acad Orthop Surg, 2014. 22(1): p. 57-62.

75. SERKIN, F.B., et al., Combat urologic trauma in US militaryoverseas contingency operations. J Trauma, 2010. 69Suppl 1: p. S175-8.

76. SANTUCCI, R.A. and J.M. BARTLEY, Urologic trauma gui-delines: a 21st century update. Nat Rev Urol, 2010. 7 (9): p.510-9.

77. JTTS, Urologic Trauma Management. 2012: San Antonio,TX.

78. WILLIAMS, M. and J. JEZIOR, Management of combat-related urological trauma in the modern era. Nat RevUrol, 2013. 10 (9): p. 504-12.

79. PANUNCIALMAN, J. and V. FALANGA, The science of

wound bed preparation. Surg Clin North Am, 2009. 89 (3):p. 611-26.

80. HAURY, B., et al., Debridement: an essential componentof traumatic wound care. Am J Surg, 1978. 135 (2): p. 238-42.

81. HINCK, D., A. FRANKE, and F. GATZKA, Use of vacuum-assisted closure negative pressure wound therapy in com-bat-related injuries--literature review. Mil Med, 2010. 175(3): p. 173-81.

82. McCALLON, S.K., et al., Vacuum-assisted closure versussaline-moistened gauze in the healing of postoperativediabetic foot wounds. Ostomy Wound Manage, 2000. 46(8): p. 28-32, 34.

83. POWELL, E.T.T., The role of negative pressure wound the-rapy with reticulated open cell foam in the treatment ofwar wounds. J Orthop Trauma, 2008. 22 (10 Suppl): p.S138-41.

84. POTTER, B.K., et al., Heterotopic ossification followingtraumatic and combat-related amputations. Prevalence,risk factors, and preliminary results of excision. J BoneJoint Surg Am, 2007. 89 (3): p. 476-86.

85. FORSBERG, J.A., et al., Heterotopic ossification in high-energy wartime extremity injuries: prevalence and riskfactors. J Bone Joint Surg Am, 2009. 91 (5): p. 1084-91.

86. TINTLE, S.M., et al., Reoperation after combat-relatedmajor lower extremity amputations. J Orthop Trauma,2014. 28 (4): p. 232-7.

87. BELLAMY, J.L., et al., Does a longer delay in fixation oftalus fractures cause osteonecrosis? J Surg Orthop Adv,2011. 20 (1): p. 34-7.

88. NAHM, N.J., T.A. MOORE, and H.A. VALLIER, Use of twograding systems in determining risks associated withtiming of fracture fixation. J Trauma Acute Care Surg,2014. 77 (2): p. 268-79.

89. WARKENTIEN, T., et al., Invasive mold infections followingcombat-related injuries. Clin Infect Dis, 2012. 55 (11): p.1441-9.

90. RODRIGUEZ, C.J., et al., Risk factors associated with inva-sive fungal infections in combat trauma. Surg Infect(Larchmt), 2014. 15 (5): p. 521-6.

91. RODRIGUEZ, C., et al., Clinical relevance of mold culturepositivity with and without recurrent wound necrosis fol-lowing combat-related injuries. J Trauma Acute Care Surg,2014. 77 (5): p. 769-773.

92. De PAUW, B., et al., Revised definitions of invasive fungaldisease from the European Organization for Research andTreatment of Cancer/Invasive Fungal InfectionsCooperative Group and the National Institute of Allergyand Infectious Diseases Mycoses Study Group(EORTC/MSG) Consensus Group. Clin Infect Dis, 2008. 46(12): p. 1813-21.

93. PAOLINO, K.M., et al., Invasive fungal infections followingcombat-related injury. Mil Med, 2012. 177 (6): p. 681-5.

94. JTTS, Treatment of Suspected Invasive Fungal Infection inWar Wounds. 2012: San Antonio, TX.

VOL.90/1



95. AKERS, K.S., et al., Antifungal wound penetration ofamphotericin and voriconazole in combat-related injuries:case report. BMC Infect Dis, 2015. 15: p. 184.

96. TRIBBLE, D.R. and C.J. RODRIGUEZ, Combat-RelatedInvasive Fungal Wound Infections. Curr Fungal Infect Rep,2014. 8 (4): p. 277-286.

97. LLOYD, B., et al., Effect of early screening for invasive fun-gal infections in U.S. service members with explosive blastinjuries. Surg Infect (Larchmt), 2014. 15 (5): p. 619-26.

98. RADOWSKY, J.S., et al., Serum Inflammatory CytokineMarkers of Invasive Fungal Infection in PreviouslyImmunocompetent Battle Casualties. Surg Infect(Larchmt), 2015. 16 (5): p. 526-32.

99. BENNDORF, M., et al., External validation of a publiclyavailable computer assisted diagnostic tool for mammo-graphic mass lesions with two high prevalence researchdatasets. Med Phys, 2015. 42 (8): p. 4987-96.

100. JACOBS, C., et al., Computer-aided detection of pulmo-nary nodules: a comparative study using the publicLIDC/IDRI database. Eur Radiol, 2015.

101. SELLAMI, L., I. NJEH, and S. LEHERICY, Towards aComputer Aided Prognosis for Brain Glioblastomas TumorGrowth Estimation. IEEE Trans Nanobioscience, 2015.

102. QURESHI, A.T., et al., Early Characterization of Blast-rela-ted Heterotopic Ossification in a Rat Model. Clin OrthopRelat Res, 2015. 473 (9): p. 2831-9.

103. POLFER, E.M., et al., The development of a rat model toinvestigate the formation of blast-related post-traumaticheterotopic ossification. Bone Joint J, 2015. 97-b (4): p.572-6.

104. ALFIERI, K.A., J.A. FORSBERG, and B.K. POTTER, Blastinjuries and heterotopic ossification. Bone Joint Res, 2012.1 (8): p. 192-7.

105. YEUNG, M., et al., Efficacy of Nonsteroidal Anti-Inflammatory Drug Prophylaxis for HeterotrophicOssification in Hip Arthroscopy: A Systematic Review.Arthroscopy, 2015.

106. MILAKOVIC, M., et al., Radiotherapy for the prophylaxisof heterotopic ossification: A systematic review and meta-analysis of randomized controlled trials. Radiother Oncol,2015. 116 (1): p. 4-9.

107. FORSBERG, J.A. and B.K. POTTER, Heterotopic ossifica-tion in wartime wounds. J Surg Orthop Adv, 2010. 19 (1):p. 54-61.

108. PAVEY, G.J., et al., Bioburden Increases HeterotopicOssification Formation in an Established Rat Model. ClinOrthop Relat Res, 2015. 473 (9): p. 2840-7.

109. BARRERA, L.M., et al., Thromboprophylaxis for traumapatients. Cochrane Database Syst Rev, 2013. 3: p.Cd008303.

110. GILLERN, S.M., et al., Incidence of pulmonary embolus incombat casualties with extremity amputations and frac-tures. J Trauma, 2011. 71 (3): p. 607-12; discussion 612-3.

111. POLI, D., et al., Incidence of recurrent venous throm-

boembolism and of chronic thromboembolic pulmonaryhypertension in patients after a first episode of pulmo-nary embolism. J Thromb Thrombolysis, 2010. 30 (3): p.294-9.

112. TAPSON, V.F., Acute Pulmonary Embolism. New EnglandJournal of Medicine, 2008. 358 (10): p. 1037-1052.

113. JTTS, The Prevention of Deep Venous Thrombosis - IVCFilter. 2012: San Antonio, TX.

114. HOLLEY, A.B., et al., Venous thromboembolism prophy-laxis for patients receiving regional anesthesia followinginjury in Iraq and Afghanistan. J Trauma Acute Care Surg,2014. 76 (1): p. 152-9.

115. CARUSO, J.D., E.A. ELSTER, and C.J. RODRIGUEZ,Epidural placement does not result in an increased inci-dence of venous thromboembolism in combat-woundedpatients. J Trauma Acute Care Surg, 2014. 77 (1): p. 61-6;discussion 66.

116. OLSON, E.J., et al., Heparin versus enoxaparin for pre-vention of venous thromboembolism after trauma: A ran-domized noninferiority trial. J Trauma Acute Care Surg,2015.

117. British Committee for Standards in HaematologyWriting, G., et al., Guidelines on use of vena cava filters.Br J Haematol, 2006. 134 (6): p. 590-5.

118. CHERRY, R.A., et al., Prophylactic inferior vena cava fil-ters: do they make a difference in trauma patients? JTrauma, 2008. 65 (3): p. 544-8.

119. HOLCOMB, J.B., et al., Understanding combat casualtycare statistics. J Trauma, 2006. 60 (2): p. 397-401.

120. OWENS, B.D., et al., Combat wounds in operation IraqiFreedom and operation Enduring Freedom. J Trauma,2008. 64 (2): p. 295-9.

121. PRUITT, B.A., Jr., T.E. RASMUSSEN, and G. GUELLER, Aformula for success in military medical research. J TraumaAcute Care Surg, 2015. 79 (4 Suppl 2): p. S64-9.

122. KRUEGER, C.A., J.C. WENKE, and J.R. FICKE, Ten years atwar: comprehensive analysis of amputation trends. JTrauma Acute Care Surg, 2012. 73 (6 Suppl 5): p. S438-44.

123. BUTLER, F.K., D.J. SMITH, and R.H. CARMONA,Implementing and preserving the advances in combatcasualty care from Iraq and Afghanistan throughout the USMilitary. J Trauma Acute Care Surg, 2015. 79 (2): p. 321-6.

124. JSOU, Special Operations Forces Reference Manual.1998, Fayetteville, NC, 28314: Cubic Applications, Inc.

125. TCCC. Tactical Combat Casualty Care Guidelines. June 2,2014 [cited 2015 August 27].

126. BECKETT, A., et al., Needle decompression for tensionpneumothorax in Tactical Combat Casualty Care: docatheters placed in the midaxillary line kink more oftenthan those in the midclavicular line? J Trauma, 2011. 71 (5Suppl 1): p. S408-12.

127. DRISCOLL, R.S., New York Chapter History of MilitaryMedicine Award. U.S. Army medical helicopters in theKorean War. Mil Med, 2001. 166 (4): p. 290-6.


VOL.90/1


95. AKERS, K.S., et al., Antifungal wound penetration ofamphotericin and voriconazole in combat-related injuries:case report. BMC Infect Dis, 2015. 15: p. 184.

96. TRIBBLE, D.R. and C.J. RODRIGUEZ, Combat-RelatedInvasive Fungal Wound Infections. Curr Fungal Infect Rep,2014. 8 (4): p. 277-286.

97. LLOYD, B., et al., Effect of early screening for invasive fun-gal infections in U.S. service members with explosive blastinjuries. Surg Infect (Larchmt), 2014. 15 (5): p. 619-26.

98. RADOWSKY, J.S., et al., Serum Inflammatory CytokineMarkers of Invasive Fungal Infection in PreviouslyImmunocompetent Battle Casualties. Surg Infect(Larchmt), 2015. 16 (5): p. 526-32.

99. BENNDORF, M., et al., External validation of a publiclyavailable computer assisted diagnostic tool for mammo-graphic mass lesions with two high prevalence researchdatasets. Med Phys, 2015. 42 (8): p. 4987-96.

100. JACOBS, C., et al., Computer-aided detection of pulmo-nary nodules: a comparative study using the publicLIDC/IDRI database. Eur Radiol, 2015.

101. SELLAMI, L., I. NJEH, and S. LEHERICY, Towards aComputer Aided Prognosis for Brain Glioblastomas TumorGrowth Estimation. IEEE Trans Nanobioscience, 2015.

102. QURESHI, A.T., et al., Early Characterization of Blast-rela-ted Heterotopic Ossification in a Rat Model. Clin OrthopRelat Res, 2015. 473 (9): p. 2831-9.

103. POLFER, E.M., et al., The development of a rat model toinvestigate the formation of blast-related post-traumaticheterotopic ossification. Bone Joint J, 2015. 97-b (4): p.572-6.

104. ALFIERI, K.A., J.A. FORSBERG, and B.K. POTTER, Blastinjuries and heterotopic ossification. Bone Joint Res, 2012.1 (8): p. 192-7.

105. YEUNG, M., et al., Efficacy of Nonsteroidal Anti-Inflammatory Drug Prophylaxis for HeterotrophicOssification in Hip Arthroscopy: A Systematic Review.Arthroscopy, 2015.

106. MILAKOVIC, M., et al., Radiotherapy for the prophylaxisof heterotopic ossification: A systematic review and meta-analysis of randomized controlled trials. Radiother Oncol,2015. 116 (1): p. 4-9.

107. FORSBERG, J.A. and B.K. POTTER, Heterotopic ossifica-tion in wartime wounds. J Surg Orthop Adv, 2010. 19 (1):p. 54-61.

108. PAVEY, G.J., et al., Bioburden Increases HeterotopicOssification Formation in an Established Rat Model. ClinOrthop Relat Res, 2015. 473 (9): p. 2840-7.

109. BARRERA, L.M., et al., Thromboprophylaxis for traumapatients. Cochrane Database Syst Rev, 2013. 3: p.Cd008303.

110. GILLERN, S.M., et al., Incidence of pulmonary embolus incombat casualties with extremity amputations and frac-tures. J Trauma, 2011. 71 (3): p. 607-12; discussion 612-3.

111. POLI, D., et al., Incidence of recurrent venous throm-

boembolism and of chronic thromboembolic pulmonaryhypertension in patients after a first episode of pulmo-nary embolism. J Thromb Thrombolysis, 2010. 30 (3): p.294-9.

112. TAPSON, V.F., Acute Pulmonary Embolism. New EnglandJournal of Medicine, 2008. 358 (10): p. 1037-1052.

113. JTTS, The Prevention of Deep Venous Thrombosis - IVCFilter. 2012: San Antonio, TX.

114. HOLLEY, A.B., et al., Venous thromboembolism prophy-laxis for patients receiving regional anesthesia followinginjury in Iraq and Afghanistan. J Trauma Acute Care Surg,2014. 76 (1): p. 152-9.

115. CARUSO, J.D., E.A. ELSTER, and C.J. RODRIGUEZ,Epidural placement does not result in an increased inci-dence of venous thromboembolism in combat-woundedpatients. J Trauma Acute Care Surg, 2014. 77 (1): p. 61-6;discussion 66.

116. OLSON, E.J., et al., Heparin versus enoxaparin for pre-vention of venous thromboembolism after trauma: A ran-domized noninferiority trial. J Trauma Acute Care Surg,2015.

117. British Committee for Standards in HaematologyWriting, G., et al., Guidelines on use of vena cava filters.Br J Haematol, 2006. 134 (6): p. 590-5.

118. CHERRY, R.A., et al., Prophylactic inferior vena cava fil-ters: do they make a difference in trauma patients? JTrauma, 2008. 65 (3): p. 544-8.

119. HOLCOMB, J.B., et al., Understanding combat casualtycare statistics. J Trauma, 2006. 60 (2): p. 397-401.

120. OWENS, B.D., et al., Combat wounds in operation IraqiFreedom and operation Enduring Freedom. J Trauma,2008. 64 (2): p. 295-9.

121. PRUITT, B.A., Jr., T.E. RASMUSSEN, and G. GUELLER, Aformula for success in military medical research. J TraumaAcute Care Surg, 2015. 79 (4 Suppl 2): p. S64-9.

122. KRUEGER, C.A., J.C. WENKE, and J.R. FICKE, Ten years atwar: comprehensive analysis of amputation trends. JTrauma Acute Care Surg, 2012. 73 (6 Suppl 5): p. S438-44.

123. BUTLER, F.K., D.J. SMITH, and R.H. CARMONA,Implementing and preserving the advances in combatcasualty care from Iraq and Afghanistan throughout the USMilitary. J Trauma Acute Care Surg, 2015. 79 (2): p. 321-6.

124. JSOU, Special Operations Forces Reference Manual.1998, Fayetteville, NC, 28314: Cubic Applications, Inc.

125. TCCC. Tactical Combat Casualty Care Guidelines. June 2,2014 [cited 2015 August 27].

126. BECKETT, A., et al., Needle decompression for tensionpneumothorax in Tactical Combat Casualty Care: docatheters placed in the midaxillary line kink more oftenthan those in the midclavicular line? J Trauma, 2011. 71 (5Suppl 1): p. S408-12.

127. DRISCOLL, R.S., New York Chapter History of MilitaryMedicine Award. U.S. Army medical helicopters in theKorean War. Mil Med, 2001. 166 (4): p. 290-6.


VOL.90/1


128. OLSON, C.M., Jr., et al., Forward aeromedical evacuation:a brief history, lessons learned from the Global War onTerror, and the way forward for US policy. J Trauma AcuteCare Surg, 2013. 75 (2 Suppl 2): p. S130-6.

129. HILL, M.G., MIKE; PANG, GERRY; KONOSKE, PAULA,Marine Corps CASEVAC: Determining Medical SupplyNeeds for Long- and Short-Range Airborne CasualtyEvacuation. NAVAL HEALTH RESEARCH CENTER SANDIEGO CA, 2004.

130. NHTSA, National EMS Scope of Practice Model, N.H.T.S.Administration, Editor. 2007, The National HighwayTraffic Safety Administration.

131. MAVITY, M.E., VAMPIRE PROGRAM CCOP-01: URGENTRESUSCITATION USING BLOOD PRODUCTS DURING TACTI-CAL EVACUATION FROM POINT OF INJURY. 2016.

132. APODACA, A., et al., Performance improvement evalua-tion of forward aeromedical evacuation platforms inOperation Enduring Freedom. J Trauma Acute Care Surg,2013. 75 (2 Suppl 2): p. S157-63.

133. MABRY, R.L., et al., Impact of critical care-trained flightparamedics on casualty survival during helicopter evacua-tion in the current war in Afghanistan. J Trauma AcuteCare Surg, 2012. 73 (2 Suppl 1): p. S32-7.

134. HOLLAND, S.R., A. APODACA, and R.L. MABRY, MEDE-VAC: survival and physiological parameters improved withhigher level of flight medic training. Mil Med, 2013. 178(5): p. 529-36.

135. MABRY, R.L. and R.A. De LORENZO, Sharpening theedge: paramedic training for flight medics. US Army MedDep J, 2011: p. 92-100.

136. TOBIN, J.M., D.K. VIA, and T. CARTER, Tactical evacua-tion: extending critical care on rotary wing platforms toforward surgical facilities. Mil Med, 2011. 176 (1): p. 4-6.

137. MORRISON, J.J., et al., En-route care capability frompoint of injury impacts mortality after severe wartimeinjury. Ann Surg, 2013. 257 (2): p. 330-4.

138. KOTWAL, R.S., et al., The Effect of a Golden Hour Policyon the Morbidity and Mortality of Combat Casualties.JAMA Surg, 2015: p. 1-10.

139. EASTRIDGE, B.J., et al., Trauma system development in atheater of war: Experiences from Operation Iraqi Freedomand Operation Enduring Freedom. J Trauma, 2006. 61 (6):p. 1366-72; discussion 1372-3.

140. EASTRIDGE, B.J., et al., Impact of joint theater traumasystem initiatives on battlefield injury outcomes. Am JSurg, 2009. 198 (6): p. 852-7.

141. BAILEY, J.A., J.J. MORRISON, and T.E. RASMUSSEN,Military trauma system in Afghanistan: lessons for civil sys-tems? Curr Opin Crit Care, 2013. 19 (6): p. 569-77.

142. TRENTZSCH, H., et al., Hypothermia for prediction ofdeath in severely injured blunt trauma patients. Shock,2012. 37 (2): p. 131-9.

143. SOREIDE, K., Clinical and translational aspects of hypo-thermia in major trauma patients: from pathophysiologyto prevention, prognosis and potential preservation.Injury, 2014. 45 (4): p. 647-54.

144. KUTCHER, M.E., et al., Evolving beyond the vicious triad:Differential mediation of traumatic coagulopathy byinjury, shock, and resuscitation. J Trauma Acute Care Surg,2015. 78 (3): p. 516-23.

145. MARTIN, R.S., et al., Injury-associated hypothermia: ananalysis of the 2004 National Trauma Data Bank. Shock,2005. 24 (2): p. 114-8.

146. INABA, K., et al., Mortality impact of hypothermia aftercavitary explorations in trauma. World J Surg, 2009. 33 (4):p. 864-9.

147. ALLEN, P.B., et al., Preventing hypothermia: comparisonof current devices used by the US Army in an in vitro war-med fluid model. J Trauma, 2010. 69 Suppl 1: p. S154-61.

148. NESBITT, M., et al., Current practice of thermoregulationduring the transport of combat wounded. J Trauma, 2010.69 Suppl 1: p. S162-7.

149. JTTS. Hypothermia Prevention, Monitoring, and Management.Joint Theater Trauma System Clinical Practice Guideline 2006September 18, 2012 August 27, 2015]; Available from:http://www.usaisr.amedd.army.mil/cpgs/Hypothermia_Prevention_20_Sep_12.pdf.

150. WALTERS, T.J. and R.L. MABRY, Issues related to the useof tourniquets on the battlefield. Mil Med, 2005. 170 (9):p. 770-5.

151. RICHEY, S.L., Tourniquets for the control of traumatichemorrhage: a review of the literature. J Spec Oper Med,2009. 9 (1): p. 56-64.

152. LAKSTEIN, D., et al., Tourniquets for hemorrhage controlon the battlefield: a 4-year accumulated experience. JTrauma, 2003. 54 (5 Suppl): p. S221-5.

153. HOLCOMB, J., et al., Causes of death in US SpecialOperations Forces in the global war on terrorism: 2001-2004. US Army Med Dep J, 2007: p. 24-37.

154. KRAGH, J.F., Jr., et al., Tragedy into drama: an americanhistory of tourniquet use in the current war. J Spec OperMed, 2013. 13 (3): p. 5-25.

155. WEPPNER, J., et al., Efficacy of tourniquets exposed tothe afghanistan combat environment stored in individualfirst aid kits versus on the exterior of plate carriers. MilMed, 2013. 178 (3): p. 334-7.

156. BULGER, E.M., et al., An evidence-based prehospital gui-deline for external hemorrhage control: American Collegeof Surgeons Committee on Trauma. Prehosp Emerg Care,2014. 18 (2): p. 163-73.

157. GATES, K.S., L. BAER, and J.B. HOLCOMB, Prehospitalemergency care: evaluation of the junctional emergencytourniquet tool with a perfused cadaver model. J SpecOper Med, 2014. 14 (1): p. 40-4.

158. KRAGH, J.F., Jr., et al., Testing of junctional tourniquetsby military medics to control simulated groin hemor-rhage. J Spec Oper Med, 2014. 14 (3): p. 58-63.

159. KHEIRABADI, B.S., et al., In vivo assessment of theCombat Ready Clamp to control junctional hemorrhagein swine. J Trauma Acute Care Surg, 2013. 74 (5): p.1260-5.

VOL.90/1



160. KRAGH, J.F., et al., Performance of JunctionalTourniquets in Normal Human Volunteers. Prehosp EmergCare, 2015. 19 (3): p. 391-8.

161. KLOTZ, J.K., et al., First case report of SAM? Junctionaltourniquet use in Afghanistan to control inguinal hemor-rhage on the battlefield. J Spec Oper Med, 2014. 14 (2): p.1-5.

162. CROUSHORN, J., Abdominal aortic and junctional tour-niquet controls hemorrhage from a gunshot wound ofthe left groin. J Spec Oper Med, 2014. 14 (2): p. 6-8.

163. KRAGH, J.F., Jr., et al., Practical use of emergency tourni-quets to stop bleeding in major limb trauma. J Trauma,2008. 64 (2 Suppl): p. S38-49; discussion S49-50.

164. BEEKLEY, A.C., et al., Prehospital tourniquet use inOperation Iraqi Freedom: effect on hemorrhage controland outcomes. J Trauma, 2008. 64 (2 Suppl): p. S28-37; dis-cussion S37.

165. KRAGH, J.F., Jr., et al., U.S. Military use of tourniquetsfrom 2001 to 2010. Prehosp Emerg Care, 2015. 19 (2): p.184-90.

166. BRODIE, S., et al., Tourniquet use in combat trauma: UKmilitary experience. J R Army Med Corps, 2007. 153 (4): p.310-3.

167. DAYAN, L., et al., Complications associated with prolon-ged tourniquet application on the battlefield. Mil Med,2008. 173 (1): p. 63-6.

168. KRAGH, J.F., Jr., et al., Survival with emergency tourni-quet use to stop bleeding in major limb trauma. Ann Surg,2009. 249 (1): p. 1-7.

169. KUE, R.C., et al., Tourniquet Use in a Civilian EmergencyMedical Services Setting: A Descriptive Analysis of theBoston EMS Experience. Prehosp Emerg Care, 2015. 19 (3):p. 399-404.

170. INABA, K., et al., Tourniquet use for civilian extremitytrauma. J Trauma Acute Care Surg, 2015. 79 (2): p. 232-7;quiz 332-3.

171. JACOBS, L.M., Implementation of the HartfordConsensus initiative to increase survival from active shoo-ter and intentional mass casualty events and to enhancethe resilience of citizens. Bull Am Coll Surg, 2015. 100 (1Suppl): p. 83-6.

172. DHS. Stop the Bleed | Homeland Security. 2016 [citedJanuary 06 2016]; Available from:http://www.dhs.gov/stopthebleed.

173. McSWAIN, N.E. and L.J. WEIRETER, Bleeding Control forthe Injured. 2015.

174. Boston marathon bombings: an after-action review. JTrauma Acute Care Surg, 2014. 77 (3): p. 501-3.

175. COUCH, K.S. and A. STOJADINOVIC, Negative-pressurewound therapy in the military: lessons learned. PlastReconstr Surg, 2011. 127 Suppl 1: p. 117s-130s.

176. PORTOU, M.J., et al., The innate immune system, toll-likereceptors and dermal wound healing: A review. VasculPharmacol, 2015. 71: p. 31-6.

177. FORSBERG, J.A., et al., Correlation of procalcitonin andcytokine expression with dehiscence of wartime extremitywounds. J Bone Joint Surg Am, 2008. 90 (3): p. 580-8.

178. HAWKSWORTH, J.S., et al., Inflammatory biomarkers incombat wound healing. Ann Surg, 2009. 250 (6): p. 1002-7.

179. HOOPER, T.J., et al., Implementation and execution ofmilitary forward resuscitation programs. Shock, 2014. 41Suppl 1: p. 90-7.

180. SPINELLA, P.C., et al., Warm fresh whole blood is inde-pendently associated with improved survival for patientswith combat-related traumatic injuries. J Trauma, 2009. 66(4 Suppl): p. S69-76.

181. PERKINS, J.G., et al., Comparison of platelet transfusionas fresh whole blood versus apheresis platelets for massi-vely transfused combat trauma patients (CME).Transfusion, 2011. 51 (2): p. 242-52.

182. RENTAS, F., et al., The Armed Services BloodProgram: blood support to combat casualty care 2001to 2011. J Trauma Acute Care Surg, 2012. 73 (6 Suppl5): p. S472-8.

183. RAINER, T.H., et al., Early risk stratification of patientswith major trauma requiring massive blood transfusion.Resuscitation, 2011. 82 (6): p. 724-9.

184. NUNEZ, T.C., et al., Early prediction of massive transfu-sion in trauma: simple as ABC (assessment of bloodconsumption)? J Trauma, 2009. 66 (2): p. 346-52.

185. POMMERENING, M.J., et al., Clinical gestalt and the pre-diction of massive transfusion after trauma. Injury, 2015.46 (5): p. 807-13.

186. YUCEL, N., et al., Trauma Associated Severe Hemorrhage(TASH)-Score: probability of mass transfusion as surrogatefor life threatening hemorrhage after multiple trauma. JTrauma, 2006. 60 (6): p. 1228-36; discussion 1236-7.

187. McLAUGHLIN, D.F., et al., A predictive model for massivetransfusion in combat casualty patients. J Trauma, 2008.64 (2 Suppl): p. S57-63; discussion S63.

188. SCHREIBER, M.A., et al., Early predictors of massive trans-fusion in combat casualties. J Am Coll Surg, 2007. 205 (4):p. 541-5.

189. MINA, M.J., A.M. WINKLER, and C.J. DENTE, Let techno-logy do the work: Improving prediction of massive trans-fusion with the aid of a smartphone application. J TraumaAcute Care Surg, 2013. 75 (4): p. 669-75.

190. HOLCOMB, J.B., et al., Increased plasma and platelet tored blood cell ratios improves outcome in 466 massivelytransfused civilian trauma patients. Ann Surg, 2008. 248(3): p. 447-58.

191. BORGMAN, M.A., et al., The ratio of blood productstransfused affects mortality in patients receiving massivetransfusions at a combat support hospital. J Trauma, 2007.63 (4): p. 805-13.

192. MOORE, F.A., B.A. McKinley, and E.E. MOORE, The nextgeneration in shock resuscitation. Lancet, 2004. 363(9425): p. 1988-96.


VOL.90/1


193. BALOGH, Z., et al., Supranormal trauma resuscitationcauses more cases of abdominal compartment syndrome.Arch Surg, 2003. 138 (6): p. 637-42; discussion 642-3.

194. SHAZ, B.H., et al., Increased number of coagulation pro-ducts in relationship to red blood cell products transfusedimproves mortality in trauma patients. Transfusion, 2010.50 (2): p. 493-500.

195. JTTS, DAMAGE CONTROL RESUSCITATION AT LEVEL IIb/IIITREATMENT FACILITIES. 2013, USAISR: San Antonio, TX.

196. MARTIN, M.J.a.B., A.C., Front Line Surgery: A PracticalApproach. 2011, New York, NY: Springer.

197. SPINELLA, P.C., et al., Constant challenges and evolutionof US military transfusion medicine and blood operationsin combat. Transfusion, 2012. 52 (5): p. 1146-53.

198. COTTON, B.A., et al., Damage control resuscitation isassociated with a reduction in resuscitation volumes andimprovement in survival in 390 damage control laparo-tomy patients. Ann Surg, 2011. 254 (4): p. 598-605.

199. DUCHESNE, J.C., et al., Damage control resuscitation incombination with damage control laparotomy: a survivaladvantage. J Trauma, 2010. 69 (1): p. 46-52.

200. HAIDER, A.H., et al., Military-to-civilian translation of battle-field innovations in operative trauma care. Surgery, 2015.

201. VOLPIN, G., et al., Cytokine levels (IL-4, IL-6, IL-8 andTGFbeta) as potential biomarkers of systemic inflamma-tory response in trauma patients. Int Orthop, 2014. 38 (6):p. 1303-9.

202. MIMASAKA, S., et al., Significance of levels of IL-6 and IL-8 after trauma: a study of 11 cytokines post-mortem usingmultiplex immunoassay. Injury, 2007. 38 (9): p. 1047-51.

203. FORSBERG, J.A., et al., Lessons of War: Turning Data IntoDecisions. EBioMedicine, 2015. 2 (9): p. 1235-42.

204. BAKER, S.P., et al., The injury severity score: a method fordescribing patients with multiple injuries and evaluatingemergency care. J Trauma, 1974. 14 (3): p. 187-96.

205. SHIN, E., K.N. EVANS, and M.E. FLEMING, Injury severityscore underpredicts injury severity and resource utiliza-tion in combat-related amputations. J Orthop Trauma,2013. 27 (7): p. 419-23.

206. TOHIRA, H., et al., Impact of the version of the abbre-viated injury scale on injury severity characterization andquality assessment of trauma care. J Trauma, 2011. 71 (1):p. 56-62.

207. LAWNICK, M.M., et al., Combat injury coding: a reviewand reconfiguration. J Trauma Acute Care Surg, 2013. 75(4): p. 573-81.

208. LUNDY, J.B. and C.M. HOBBS, 'Bastion classification':

evolution of experience mandates caution when conside-ring using class as predictor for method of temporary vas-cular control. Injury, 2013. 44 (11): p. 1671-2.

209. MOSSADEGH, S., M. MIDWINTER, and P. PARKER,Developing a cumulative anatomic scoring system for mili-tary perineal and pelvic blast injuries. J R Army Med Corps,2013. 159 Suppl 1: p. i40-4.

210. GUPTA, B.K., et al., The role of intra-aortic balloon occlu-sion in penetrating abdominal trauma. J Trauma, 1989. 29(6): p. 861-5.

211. BRENNER, M.L., et al., A clinical series of resuscitativeendovascular balloon occlusion of the aorta for hemor-rhage control and resuscitation. J Trauma Acute CareSurg, 2013. 75 (3): p. 506-11.

212. SAITO, N., et al., Evaluation of the safety and feasibilityof resuscitative endovascular balloon occlusion of theaorta. J Trauma Acute Care Surg, 2015. 78 (5): p. 897-903;discussion 904.

213. JTTS, Resuscitative Endovascular Balloon Occlusion ofthe Aorta (REBOA) for Hemorrhagic Shock. 2014.

214. SCOTT, D.J., et al., A novel fluoroscopy-free, resuscitativeendovascular aortic balloon occlusion system in a modelof hemorrhagic shock. J Trauma Acute Care Surg, 2013. 75(1): p. 122-8.

215. SALM, L., P. AVERY, and F. BIRD, London TraumaConference 2014, in Scand J Trauma Resusc Emerg Med.2015. p. A1.

216. TENGBORN, L., M. BLOMBACK, and E. BERNTORP,Tranexamic acid--an old drug still going strong andmaking a revival. Thromb Res, 2015. 135 (2): p. 231-42.

217. HUNT, B.J., The current place of tranexamic acid in themanagement of bleeding. Anaesthesia, 2015. 70 Suppl 1:p. 50-3, e18.

218. MORRISON, J.J., et al., Military Application ofTranexamic Acid in Trauma Emergency Resuscitation(MATTERs) Study. Arch Surg, 2012. 147 (2): p. 113-9.

219. MORRISON, J.J., et al., Association of cryoprecipitate andtranexamic acid with improved survival following war-time injury: findings from the MATTERs II Study. JAMASurg, 2013. 148 (3): p. 218-25.

220. JIMENEZ, J.J., et al., Tranexamic acid attenuates inflam-matory response in cardiopulmonary bypass surgerythrough blockade of fibrinolysis: a case control study fol-lowed by a randomized double-blind controlled trial. CritCare, 2007. 11 (6): p. R117.

221. JIMENEZ, J.J., et al., Safetyand effectiveness of two treat-ment regimes with tranexamic acid to minimize inflam-matory response in elective cardiopulmonary bypasspatients: a randomized double-blind, dose-dependent,phase IV clinical trial. J Cardiothorac Surg, 2011. 6: p. 138.

VOL.90/1



Complex Blast Injuries ROTHBERG.qxp Mise en page 1 … · 2017-12-05 · Blast injuries are...

Documents

Transcript of Complex Blast Injuries ROTHBERG.qxp Mise en page 1 … · 2017-12-05 · Blast injuries are...