Lorne H. Blackbourne

Selective nonoperative management of combat-related blunt splenic injury (BSI) is controversial. We evaluated the impact of the November 2008 blunt abdominal trauma clinical practice guideline that permitted selective nonoperative management of some patients with radiological suggestion of hemoperitoneum on implementation of nonoperative management (NOM) of splenic injury in austere environments.Retrospective evaluation of patients with splenic injuries from November 2002 through January 2012 in Iraq and Afghanistan was performed. International Classification of Diseases, 9th Revision, Clinical Modification procedure codes identified patients as laparotomy with splenectomy, or NOM. Delayed operative management had no operative intervention at earlier North American Treaty Organization (NATO) medical treatment facilities (MTFs), and had a definitive intervention at a latter NATO MTFs. Intra-abdominal complications and overall mortality were juxtaposed.A total of 433 patients had splenic injuries from 2002 to 2012. Initial NOM of BSI from 2002 to 2008 compared to 2009-2012 was 44.1% and 47.2%, respectively (p=0.75). Delayed operative management and NOM completion had intra-abdominal complication and mortality rates of 38.1% and 9.1% (p<0.01), and 6.3% and 8.1% (p=0.77).Despite high-energy explosive injuries, NATO Role II MTFs radiological constraints and limited medical resources, hemodynamically normal patients with BSI and low abdominal abbreviated injury scores underwent NOM in austere environments.

Mortality from thoracic injuries has declined significantly from 63% in the Civil War to 3% in Vietnam. We reviewed the injury patterns, procedures, blood products, and mortality of US soldiers sustaining a thoracic injury during Operation Enduring Freedom and Iraqi Freedom (OEF/OIF). Data on US soldiers with a thoracic injury during OEF/OIF from January 2003 to May 2011 was collected from the Joint Theater Trauma Registry. Coalition forces, civilians, and soldiers killed in action were excluded. Injuries and procedures were identified using DRG International Classification of Diseases-9th Rev. and Abbreviated Injury Scale (AIS) codes. Data are presented as mean (SD). Statistical analysis used χ analysis and t test where appropriate. Thoracic injuries occurred in 2,049 of 23,797 wounded US military personnel for a prevalence of 8.6%. Mean (SD) age was 26 (6.6) years, and mean (SD) chest AIS score was 2.9 (0.9). Penetrating trauma was the most common mechanism of injury (61.5%), and explosive devices were the most common cause of injury (61.9%). Of 6,030 thoracic injuries identified, pneumothorax and pulmonary contusions were most common (51.8% and 50.2%, respectively). Of 1,541 surgical procedures performed in theater, the most common was tube thoracostomy (47.1%). Most patients with penetrating fragmentation injuries (84%) were managed with tube thoracostomy as sole therapeutic intervention. The fresh frozen plasma-to-packed red blood cells ratio was 0.86. Overall mortality was 8.3%. Acute respiratory distress syndrome and inhalation injury were associated with mortality (p < 0.006). Most penetrating fragmentation injuries can be managed with tube thoracostomy. Mortality of patients with chest injury in OEF/OIF is higher than in Korea and Vietnam. This most likely represents advances in prehospital care, personal protective equipment, and rapid transport that have resulted in more severely injured patients arriving alive to a medical facility. Epidemiologic study, level IV.

Background: Studies have shown decreased mortality after improvements in combat casualty care, including increased fresh frozen plasma (FFP):red blood cell (RBC) ratios. The objective was to evaluate the evolution and impact of improved combat casualty care at different time periods of combat operations. Methods: A retrospective review was performed at one combat support hospital in Iraq of patients requiring both massive transfusion (≥10 units RBC in 24 hours) and exploratory laparotomy. Patients were divided into two cohorts based on year wounded: C1 between December 2003 and June 2004, and C2 between September 2007 and May 2008. Admission data, amount of blood products and fluid transfused, and 48 hour mortality were compared. Statistical significance was set at p < 0.05. Results: There was decreased mortality in C2 (47% vs. 20%). Patients arrived warmer with higher hemoglobin. They were transfused more RBC and FFP in the emergency department (5 units ± 3 units vs. 2 units ± 2 units; 3 units ± 2 units vs. 0 units ± 1 units, respectively) and received less crystalloid in operating room (3.3 L ± 2.2 L vs. 8.5 L ± 4.9 L). The FFP:RBC ratio was also closer to 1:1 in C2 (0.775 ± 0.32 vs. 0.511 ± 0.21). Conclusions: The combination of improved prehospital care, trauma systems approach, performance improvement projects, and improved transfusion or resuscitation practices have led to a 50% decrease in mortality for this critically injured population. We are now transfusing blood products in a ratio more consistent with 1 FFP to 1 RBC. Simultaneously, crystalloid use has decreased by 61%, all of which is consistent with hemostatic resuscitation principles.

Indications and evidence are limited, multiple and complex for emergency tourniquet use. Good recent outcomes challenge historically poor outcomes. Optimal tourniquet use in trauma care appears to depend on adequate devices, modern doctrine, refined training, speedy evacuation, and performance improvement. Challenges remain in estimation of blood loss volumes, lesion lethality, and casualty propensity to survive hemorrhage. Evidence gaps persist regarding emergency tourniquet use indications in prehospital and emergency department settings as indication data are rarely reported. Data on emergency tourniquet use was analyzed from a large clinical study (NCT00517166 at ClinicalTrials.gov). The study included 728 casualties with 953 limbs with tourniquets. The median casualty age was 26 years (range, 4-70). We compared all other known datasets to this clinical study. Tourniquet use was prehospital in 671 limbs (70%), hospital only in 104 limbs (11%), and both prehospital and hospital in 169 limbs (18%).Major hemorrhage was observed at or before the hospital in 487 (51%) limbs and minor hemorrhage was observed at the hospital in 463 limbs (49%). Anatomic lesions indicating tourniquets included open fractures (27%), amputations (26%), soft tissue wounds (20%), and vascular wounds (17%). Situations, as opposed to anatomic lesions, indicating tourniquets included bleeding from multiple sites other than limbs (24%), hospital mass casualty situations (1%), one multiple injury casualty needed an airway procedure, and one casualty had an impaled object. The current indication for emergency tourniquet use is any compressible limb wound that the applier assesses as having possibly lethal hemorrhage. This indication has demonstrated good outcomes only when devices, training, doctrine, evacuation, and research have been optimal. Analysis of emergency tourniquet indications is complex and inadequately evidenced, and further study is prudent. Prehospital data reporting may fill knowledge gaps.