Analysis of Pediatric Trauma in Combat Zone to Inform High-Fidelity Simulation Predeployment Training.

OBJECTIVES: The military uses "just-in-time" training to refresh deploying medical personnel on skills necessary for medical and surgical care in the theater of operations. The burden of pediatric care at Role 2 facilities has yet to be characterized; pediatric predeployment training has been extremely limited and primarily informed by anecdotal experience. The goal of this analysis was to describe pediatric care at Role 2 facilities to enable data-driven development of high-fidelity simulation training and core knowledge concepts specific to the combat zone. SETTING AND PATIENTS: A retrospective review of the Role 2 Database was conducted on all pediatric patients (< 18 yr) admitted to Role 2 in Afghanistan from 2008-2014. INTERVENTIONS: Three cohorts were determined based on commercially available simulation models: Group 1: less than 1 year, Group 2: 1-8 years, Group 3: more than 8 years. The groups were sub-stratified by point of injury care, pre-hospital management, and Role 2 facility medical/surgical management. MEASUREMENTS AND MAIN RESULTS: Appropriate descriptive statistics (chi square and Student t test) were utilized to define demographic and epidemiologic characteristics of this population. Of 15,404 patients in the Role 2 Database, 1,318 pediatric subjects (8.5%) were identified. The majority of patients were male (80.0%) with a mean age of 9.5 years (± SD, 4.5). Injury types included: penetrating (56%), blunt (33%), and burns (7%). Mean transport time from point of injury to Role 2 was 198 minutes (±24.5 min). Mean Glasgow Coma Scale and Revised Trauma Score were 14 (± 0.1) and 7.0 (± 1.4), respectively. Role 2 surgical procedures occurred for 424 patients (32%). Overall mortality was 4% (n = 58). CONCLUSIONS: We have described the epidemiology of pediatric trauma admitted to Role 2 facilities, characterizing the spectrum of pediatric injuries that deploying providers should be equipped to manage. This analysis will function as a needs assessment to facilitate high-fidelity simulation training and the development of "pediatric trauma core knowledge concepts" for deploying providers.

Association of Prehospital Blood Product Transfusion During Medical Evacuation of Combat Casualties in Afghanistan With Acute and 30-Day Survival.

IMPORTANCE: Prehospital blood product transfusion in trauma care remains controversial due to poor-quality evidence and cost. Sequential expansion of blood transfusion capability after 2012 to deployed military medical evacuation (MEDEVAC) units enabled a concurrent cohort study to focus on the timing as well as the location of the initial transfusion. OBJECTIVE: To examine the association of prehospital transfusion and time to initial transfusion with injury survival. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of US military combat casualties in Afghanistan between April 1, 2012, and August 7, 2015. Eligible patients were rescued alive by MEDEVAC from point of injury with either (1) a traumatic limb amputation at or above the knee or elbow or (2) shock defined as a systolic blood pressure of less than 90 mm Hg or a heart rate greater than 120 beats per minute. EXPOSURES: Initiation of prehospital transfusion and time from MEDEVAC rescue to first transfusion, regardless of location (ie, prior to or during hospitalization). Transfusion recipients were compared with nonrecipients (unexposed) for whom transfusion was delayed or not given. MAIN OUTCOMES AND MEASURES: Mortality at 24 hours and 30 days after MEDEVAC rescue were coprimary outcomes. To balance injury severity, nonrecipients of prehospital transfusion were frequency matched to recipients by mechanism of injury, prehospital shock, severity of limb amputation, head injury, and torso hemorrhage. Cox regression was stratified by matched groups and also adjusted for age, injury year, transport team, tourniquet use, and time to MEDEVAC rescue. RESULTS: Of 502 patients (median age, 25 years [interquartile range, 22 to 29 years]; 98% male), 3 of 55 prehospital transfusion recipients (5%) and 85 of 447 nonrecipients (19%) died within 24 hours of MEDEVAC rescue (between-group difference, -14% [95% CI, -21% to -6%]; P = .01). By day 30, 6 recipients (11%) and 102 nonrecipients (23%) died (between-group difference, -12% [95% CI, -21% to -2%]; P = .04). For the 386 patients without missing covariate data among the 400 patients within the matched groups, the adjusted hazard ratio for mortality associated with prehospital transfusion was 0.26 (95% CI, 0.08 to 0.84, P = .02) over 24 hours (3 deaths among 54 recipients vs 67 deaths among 332 matched nonrecipients) and 0.39 (95% CI, 0.16 to 0.92, P = .03) over 30 days (6 vs 76 deaths, respectively). Time to initial transfusion, regardless of location (prehospital or during hospitalization), was associated with reduced 24-hour mortality only up to 15 minutes after MEDEVAC rescue (median, 36 minutes after injury; adjusted hazard ratio, 0.17 [95% CI, 0.04 to 0.73], P = .02; there were 2 deaths among 62 recipients vs 68 deaths among 324 delayed transfusion recipients or nonrecipients). CONCLUSIONS AND RELEVANCE: Among medically evacuated US military combat causalities in Afghanistan, blood product transfusion prehospital or within minutes of injury was associated with greater 24-hour and 30-day survival than delayed transfusion or no transfusion. The findings support prehospital transfusion in this setting.

An Analysis of Head and Neck Surgical Workload During Recent Combat Operations From 2002 to 2016.

INTRODUCTION: In battle-injured U.S. service members, head and neck (H&N) injuries have been documented in 29% who were treated for wounds in deployed locations and 21% who were evacuated to a Role 4 MTF. The purpose of this study is to examine the H&N surgical workload at deployed U.S. military facilities in Iraq and Afghanistan in order to inform training, needed proficiency, and MTF manning. MATERIALS AND METHODS: A retrospective analysis of the DoD Trauma Registry was performed for all Role 2 and Role 3 MTFs, from January 2002 to May 2016; 385 ICD-9 CM procedure codes were identified as H&N surgical procedures and were stratified into eight categories. For the purposes of this analysis, H&N procedures included dental, ophthalmologic, airway, ear, face, mandible maxilla, neck, and oral injuries. Traumatic brain injuries and vascular injuries to the neck were excluded. RESULTS: A total of 15,620 H&N surgical procedures were identified at Role 2 and Role 3 MTFs. The majority of H&N surgical procedures (14,703, 94.14%) were reported at Role 3 facilities. Facial bone procedures were the most common subgroup across both roles of care (1,181, 75.03%). Tracheostomy accounted for 16.67% of all H&N surgical procedures followed by linear repair of laceration of eyelid or eyebrow (8.23%) and neck exploration (7.41%). H&N caseload was variable. CONCLUSIONS: H&N procedures accounted for 8.25% of all surgical procedures performed at Role 2 and Role 3 MTFs; the majority of procedures were eye (40.54%) and airway (18.50%). These data can be used as planning tools to help determine the medical footprint and also to help inform training and sustainment requirements for deployed military general surgeons especially if future contingency operations are more constrained in terms of resources and personnel.

Combat thoracic surgery in Iraq and Afghanistan: 2002-2016.

BACKGROUND: Thoracic surgery constitutes 2.5% of surgical procedures performed in theater, but the skills required are increasingly foreign to military surgeons. This study examines thoracic surgical workload in Iraq and Afghanistan to help define surgical training gaps. METHODS: Retrospective analysis of Department of Defense Trauma Registry for all role 2 (R2) (forward surgical) and role 3 (R3) (theater) military facilities, from January 2002 to May 2016. The 95 thoracic surgical International Classification of Diseases-9th Rev.-Clinical Modification procedure codes were grouped into 10 categories based on anatomy or endoscopy. Select groups were further stratified by type of definitive procedure. Procedure groupings were determined and adjudicated by surgeon subject matter experts. Data analysis used Stata Version 15 (College Station, TX). RESULTS: Of the total procedures, 5,301 were classified as thoracic surgical procedures and were included in the present study. The majority of thoracic surgical procedures (4,645 [87.6%]) were recorded as being performed at R3 medical treatment facilities (MTFs). The thoracic surgical procedures groups with the largest proportions were: bronchoscopy (39.1%), thoracotomy (16.9%), diaphragm (15.6%), and lung (11.4%). The most common lung procedure subgroup, aside from not otherwise specified, was segmentectomy (28.8%). The R3 MTFs recorded nearly five times the number of lung procedures compared with R2 MTFs; with R3 MTFs recording more than eight times the number of lobectomies compared with R2 MTFs. Thoracic workload was variable over the 15-year study period. CONCLUSION: Thoracic surgical skills are necessary in the deployed environment to manage combat-related injuries. Given the current trends in training and specialization, development and sustainment of thoracic surgical skills is challenging in the deployed US trauma system and likely for other nations, and humanitarian surgical care as well. Current training and practice paradigms pose both training and sustainment challenges for surgeons who deploy to a combat zone. LEVEL OF EVIDENCE: Therapeutic/Care Management IV.

Establishing an enduring Military Trauma Mortality Review: Misconceptions and lessons learned.

Under direction from the Defense Health Agency, subject matter experts (SMEs) from the Joint Trauma System, Armed Forces Medical Examiner System, and civilian sector established the Military Trauma Mortality Review process. To establish the most empirically robust process, these SMEs used both qualitative and quantitative methods published in a series of peer-reviewed articles over the last 3 years. Most recently, the Military Mortality Review process was implemented for the first time on all battle-injured service members attached to the United States Special Operations Command from 2001 to 2018. The current Military Mortality Review process builds on the strengths and limitations of important previous work from both the military and civilian sector. To prospectively improve the trauma care system and drive preventable death to the lowest level possible, we present the main misconceptions and lessons learned from our 3-year effort to establish a reliable and sustainable Military Trauma Mortality Review process. These lessons include the following: (1) requirement to use standardized and appropriate lexicon, definitions, and criteria; (2) requirement to use a combination of objective injury scoring systems, forensic information, and thorough SME case review to make injury survivability and death preventability determinations; (3) requirement to use nonmedical information to make reliable death preventability determinations and a comprehensive list of opportunities for improvement to reduce preventable deaths within the trauma care system; and (4) acknowledgment that the military health system still has gaps in current infrastructure that must be addressed to globally and continuously implement the process outlined in the Military Trauma Mortality Review process in the future. LEVEL OF EVIDENCE: Level III.

Tactical Combat Casualty Care Training, Knowledge, and Utilization in the US Army.

INTRODUCTION: Tactical Combat Casualty Care (TCCC) is the execution of prehospital trauma skills in the combat environment. TCCC was recognized by the 2018 Department of Defense Instruction on Medical Readiness Training as a critical wartime task. This study examines the training, understanding, and utilization of TCCC principles and guidelines among US Army medical providers and examines provider confidence of medics in performing TCCC skills. MATERIALS AND METHODS: A cross-sectional survey, developed by members of the Committee on TCCC, was distributed to all US Army Physicians and Physician Assistants via anonymous electronic communication. RESULTS: A total of 613 completed surveys were included in the analyses. Logistic regression analyses were conducted on: TCCC test score of 80% or higher, confidence with medic utilization of TCCC, and medic utilization of ketamine in accordance with TCCC. CONCLUSIONS: <60% of respondents expressed confidence in the ability of the medics to perform all TCCC skills. Supervising providers who that believed 80 to 100% of their medics had completed TCCC training had more confidence in their medic's TCCC abilities. With TCCC, a recognized lifesaver on the battlefield, continued training and utilization of TCCC concepts are paramount for deploying personnel.

An Analysis of Orthopedic Surgical Procedures Performed During U.S. Combat Operations from 2002 to 2016.

INTRODUCTION: Orthopedic surgery constitutes 27% of procedures performed for combat injuries. General surgeons may deploy far forward without orthopedic surgeon support. This study examines the type and volume of orthopedic procedures during 15 years of combat operations in Iraq and Afghanistan. MATERIALS AND METHODS: Retrospective analysis of the US Department of Defense Trauma Registry (DoDTR) was performed for all Role 2 and Role 3 facilities, from January 2002 to May 2016. The 342 ICD-9-CM orthopedic surgical procedure codes identified were stratified into fifteen categories, with upper and lower extremity subgroups. Data analysis used Stata Version 14 (College Station, TX). RESULTS: A total of 51,159 orthopedic procedures were identified. Most (43,611, 85.2%) were reported at Role 3 s. More procedures were reported on lower extremities (21,688, 57.9%). Orthopedic caseload was extremely variable throughout the 15-year study period. CONCLUSIONS: Orthopedic surgical procedures are common on the battlefield. Current dispersed military operations can occur without orthopedic surgeon support; general surgeons therefore become responsible for initial management of all injuries. Debridement of open fracture, fasciotomy, amputation and external fixation account for 2/3 of combat orthopedic volume; these procedures are no longer a significant part of general surgery training, and uncommonly performed by general/trauma surgeons at US hospitals. Given their frequency in war, expertise in orthopedic procedures by military general surgeons is imperative.

Description of trauma among French service members in the Department of Defense Trauma Registry: understanding the nature of trauma and the care provided.

BACKGROUND: Since 2001, the French Armed Forces have sustained many casualties during the Global War on Terror; however, even today, there is no French Military trauma registry. Some French service members (SMs) were treated in US Military Medical Treatment Facilities (MTFs) and were recorded in the US Department of Defense Trauma Registry (DoDTR). Our objective was to conduct a descriptive analysis of the injuries sustained by French SMs reported in the DoDTR and subsequent care provided to them to assist in understanding the importance of building a French Military trauma registry. METHODS: Using DoDTR data collected from 2001 to 2017, a retrospective descriptive analysis was conducted. We identified 59 French SMs treated in US MTFs. The characteristics of the SMs' demographics, injuries, care provided to them, and discharge outcomes were summarized. RESULTS: Among the 59 French SMs identified, 46 (78%) sustained battle injuries (BIs) and 13 (22%) sustained nonbattle injuries (NBIs). There were 47 (80%) SMs injured in Afghanistan (Opération Pamir), while 12 (20%) were injured in Opération Chammal in Iraq and Syria. Explosives accounted for 52.5% of injuries, while 25.4% were due to gunshot wounds; all were BIs. The majority of reported injuries were penetrating (59.3%), most of which were BIs (71.7%). The mean Injury Severity Score for BIs was 12 (SD = 8.9) compared to 6 (SD = 1.7) for NBIs. Around half of SMs (n = 30; 51%) were injured in Afghanistan between the years 2008-2010. Among a total of 246 injuries sustained by 59 patients, extremities were the body part most prone to BIs followed by the head and face. Four SMs died after admission (6.8%). CONCLUSIONS: The DoDTR provides extensive data on trauma injuries that can be used to inform injury prevention and clinical care. The majority of injuries sustained by French SMs were BIs, caused by explosives, and predominantly occurring to the extremities; these findings are similar to those of other studies conducted in combat zones. There is a need to establish a French Military trauma registry to improve the combat casualty care provided to French SMs, and its creation may benefit from the DoDTR model.

Correction to: Description of trauma among French service members in the Department of Defense Trauma Registry: understanding the nature of trauma and the care provided.

After publication of this article [1], it was brought to our attention that the Fig. 2 is incorrect. The correct Fig. 2 is as below.

Use of Combat Casualty Care Data to Assess the US Military Trauma System During the Afghanistan and Iraq Conflicts, 2001-2017.

Importance: Although the Afghanistan and Iraq conflicts have the lowest US case-fatality rates in history, no comprehensive assessment of combat casualty care statistics, major interventions, or risk factors has been reported to date after 16 years of conflict. Objectives: To analyze trends in overall combat casualty statistics, to assess aggregate measures of injury and interventions, and to simulate how mortality rates would have changed had the interventions not occurred. Design, Setting, and Participants: Retrospective analysis of all available aggregate and weighted individual administrative data compiled from Department of Defense databases on all 56 763 US military casualties injured in battle in Afghanistan and Iraq from October 1, 2001, through December 31, 2017. Casualty outcomes were compared with period-specific ratios of the use of tourniquets, blood transfusions, and transport to a surgical facility within 60 minutes. Main Outcomes and Measures: Main outcomes were casualty status (alive, killed in action [KIA], or died of wounds [DOW]) and the case-fatality rate (CFR). Regression, simulation, and decomposition analyses were used to assess associations between covariates, interventions, and individual casualty status; estimate casualty transitions (KIA to DOW, KIA to alive, and DOW to alive); and estimate the contribution of interventions to changes in CFR. Results: In aggregate data for 56 763 casualties, CFR decreased in Afghanistan (20.0% to 8.6%) and Iraq (20.4% to 10.1%) from early stages to later stages of the conflicts. Survival for critically injured casualties (Injury Severity Score, 25-75 [critical]) increased from 2.2% to 39.9% in Afghanistan and from 8.9% to 32.9% in Iraq. Simulations using data from 23 699 individual casualties showed that without interventions assessed, CFR would likely have been higher in Afghanistan (15.6% estimated vs 8.6% observed) and Iraq (16.3% estimated vs 10.1% observed), equating to 3672 additional deaths (95% CI, 3209-4244 deaths), of which 1623 (44.2%) were associated with the interventions studied: 474 deaths (12.9%) (95% CI, 439-510) associated with the use of tourniquets, 873 (23.8%) (95% CI, 840-910) with blood transfusion, and 275 (7.5%) (95% CI, 259-292) with prehospital transport times. Conclusions and Relevance: Our analysis suggests that increased use of tourniquets, blood transfusions, and more rapid prehospital transport were associated with 44.2% of total mortality reduction. More critically injured casualties reached surgical care, with increased survival, implying improvements in prehospital and hospital care.

Patterns of Anatomic Injury in Critically Injured Combat Casualties: A Network Analysis.

A mortality review of death caused by injury requires a determination of injury survivability prior to a determination of death preventability. If injuries are nonsurvivable, only non-medical primary prevention strategies have potential to prevent the death. Therefore, objective measures are needed to empirically inform injury survivability from complex anatomic patterns of injury. As a component of injury mortality reviews, network structures show promise to objectively elucidate survivability from complex anatomic patterns of injury resulting from explosive and firearm mechanisms. In this network analysis of 5,703 critically injured combat casualties, patterns of injury among fatalities from explosive mechanisms were associated with both a higher number and severity of anatomic injuries to regions such as the extremities, abdomen, and thorax. Patterns of injuries from a firearm were more isolated to individual body regions with fatal patterns involving more severe injuries to the head and thorax. Each injury generates a specific level of risk as part of an overall anatomic pattern to inform injury survivability not always captured by traditional trauma scoring systems. Network models have potential to further elucidate differences between potentially survivable and nonsurvivable anatomic patterns of injury as part of the mortality review process relevant to improving both the military and civilian trauma care systems.

Nonfatal motor vehicle related injuries among deployed US Service members: Characteristics, trends, and risks for limb amputations.

BACKGROUND: Motor vehicle-related (MVR) incidents are important causes of morbidity among deployed US service members (SMs). Nonbattle MVR injuries are usually similar to civilian MVR injuries, while battle MVR injuries are often unique due to the blast effects from precipitating explosive mechanisms. Our primary objective was to describe the characteristics and trends of nonfatal MVR injuries sustained by deployed US SMs. A second objective was to assess the association between mechanism of injury (i.e., explosive vs. nonexplosive) and limb amputation. METHODS: We conducted a retrospective cross-sectional analysis using data from the Department of Defense Trauma Registry collected from October 2001 to December 2018. Descriptive statistics were reported stratified by mechanism of injury (explosive vs. nonexplosive). The association between mechanism of injury and limb amputation was assessed using logistic regression models. RESULTS: There were 3,119 US casualties who sustained nonfatal MVR injuries, 2,380 (76.3%) SMs sustained nonexplosive MVR injuries while 739 (23.7%) sustained explosive MVR injuries. Of all MVR casualties, 2,085 (66.9%) were in Iraq or Syria and 1034 (33.1%) in Afghanistan. The annual prevalence of nonfatal MVR battle casualties was highest in Iraq and Syria from 2003 to 2009 and Afghanistan from 2009 to 2014, ranging overall 15 to 50 MVR casualties per 1,000 wounded in action. There were 92 limb amputations associated with MVR incidents. Compared with nonexplosive MVR mechanisms, explosive MVR mechanisms had higher association with limb amputation (adjusted odds ratio, 2.6; confidence interval, 1.7-3.9), even after adjusting for injury year and Injury Severity Score (AOR, 2.1; confidence interval: 1.4-3.4). CONCLUSION: Motor vehicle-related incidents are an important cause of injury in US military operations. Compared with nonexplosive MVR incidents, explosive MVR incidents result in more severe injuries, and have a higher associated risk of limb amputation. Continued efforts to improve injury prevention through protective equipment and medical training specific to MVR injuries are needed. LEVEL OF EVIDENCE: Prognostic and epidemiological study, Level III.

Vascular surgery during U.S. combat operations from 2002 to 2016: Analysis of vascular procedures performed to inform military training.

BACKGROUND: Vascular surgery constitutes approximately 6.5% of surgical procedures performed for combat injuries, yet general surgeons are increasingly unfamiliar with vascular surgery. This study examines the frequency and type of vascular surgical procedures performed during recent US Military operations from 2002 to 2016. METHODS: A retrospective analysis of the Department of Defense Trauma Registry was performed for all Role (R)2 and R3 medical treatment facilities (MTFs), from January 2002 to May 2016. A total of 106 International Classification of Diseases-9th Rev.-Clinical Modification (ICD-9-CM) procedure codes were categorized as vascular and were included in the present analysis. Procedure codes were separated by anatomic location and procedure type. Ligation as part of an amputation was excluded. Grafts were further subdivided by type: synthetic, autologous, and unknown. Procedure grouping and categorization were determined by subject matter experts. Data analysis used Stata Version 14 (College Station, TX). RESULTS: A total of 25,816 vascular surgical procedures were identified at R2 and R3 MTFs. Role 3 MTFs reported more than four times the number of procedures compared to R2 MTFs. The most common anatomic locations documented were extremity (64.96%) and not otherwise specified (28.1%). The most common procedures overall were amputation (33.36%) and fasciotomy (18.83%). The most common graft type was autologous (68.87%), and the least common was synthetic (5.69%). CONCLUSION: While amputation, fasciotomy, and ligation were the most common vascular procedures performed for combat trauma, the need for definitive repair including grafting is common at both R2 and R3 MTFs. Vascular surgery therefore remains a necessary skill set for the deployed US Military surgeon; military general surgeons need to train and sustain their vascular skills, including proficiency at amputation and fasciotomy. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Abdominal trauma surgery during recent US combat operations from 2002 to 2016.

BACKGROUND: Abdominal surgery constitutes approximately 13% of surgical procedures performed for combat injuries. This study examines the frequencies and type of abdominal surgical procedures performed during recent US Military operations. METHODS: A retrospective analysis of the Department of Defense Trauma Registry was performed for all Role 2 (R2) and Role 3 (R3) medical treatment facilities (MTFs), from January 2002 to May 2016. The 273 International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes that were identified as abdominal surgical procedures were stratified into 24 groups based on anatomic and functional classifications and then grouped by whether they were laparoscopic. Procedure grouping and categorization were determined, and adjudicated if necessary, by subject matter experts. Data analysis used Stata version 14 (College Station, TX). RESULTS: A total of 26,548 abdominal surgical procedures were identified at R2 and R3 MTFs. The majority of abdominal surgical procedures were reported at R3 facilities. The largest procedure group at both R2 and R3 MTFs were procedures involving the bowel. There were 18 laparoscopic procedures reported (R2: 4 procedures, R3: 14 procedures). Laparotomy not otherwise specified was the second largest procedure group at both R2 (1,060 [24.55%]) and R3 (4,935 [22.2%]) MTFs. Abdominal caseload was variable over the 15-year study period. CONCLUSIONS: Surgical skills such as open laparotomy and procedures involving the bowel are crucial in war surgery. The abundance of laparotomy not otherwise specified may reflect inadequate documentation, or the plethora of second- and third-look operations and washouts performed for complex abdominal injuries. Traditional elective general surgical cases (gallbladder, hernia) were relatively infrequent. Laparoscopy was almost nonexistent. Open abdominal surgical skills therefore remain a necessity for the deployed US Military General Surgeons; this is at odds with the shifting paradigm from open to laparoscopic skills in stateside civilian and military hospitals. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Neurosurgical workload during US combat operations: 2002 to 2016.

BACKGROUND: Approximately 4.5% of surgical procedures performed at Role 2 (R2) (forward surgical) and Role 3 (R3) (theater) medical treatment facilities can be classified as neurosurgical. These procedures are foreign to the routine daily practice of the military general surgeon. The purpose of this study was to examine the neurosurgical workload in Iraq and Afghanistan in order to inform the future predeployment neurosurgical training needs of nonneurosurgical providers. METHODS: Retrospective analysis of the Department of Defense Trauma Registry for all R2 and R3 medical facilities, from January 2002 to May 2016. The 103 neurosurgical International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes identified were grouped by anatomic location. Select groups were further subdivided. Data analysis used Stata version 14 (College Station, TX). RESULTS: A total of 7,509 neurosurgical procedures were identified. The majority (7,244 [96.5%]) occurred at R3 theater hospitals. Cranial procedures were the most common at both R2 (120, 45.3%) and R3 (4,483 [61.9%]), with craniotomy/craniectomy the most frequent procedure. Spine procedures were performed almost exclusively at R3, with 61.1% being fusions/stabilizations and 26.9% being spinal decompression alone. Neurosurgical caseload was variable over the 15-year study period, dropping to almost zero in 2016. CONCLUSIONS: Neurosurgical procedures were performed primarily at larger R3 theater hospitals where neurosurgeons were assigned if present in theater; however, more than 100 cranial procedures were performed at forward R2 where neurosurgeons were not deployed. Considering that neurosurgeons are not everywhere available within the war zone, deploying general surgeons should have familiarity with trauma neurosurgery. LEVEL OF EVIDENCE: Epidemiologic study, level III; Care Management, level IV.

High Bilateral Amputations and Dismounted Complex Blast Injury (DCBI).

High, combat-related bilateral lower extremity amputations rarely occur in isolation. Dismounted complex blast injury is a devastating and life-threatening constellation of multisystem injuries most commonly due to dismounted contact with improvised explosive devices. Rapid damage control resuscitation and surgery are essential to improve patient survival and minimize both early complications and late sequelae. A coordinated team approach is essential to provide simultaneous airway management, volume resuscitation (ideally with whole blood or ratio transfusion), and immediate control of life-threatening hemorrhage. Temporary aortic or iliac vessel clamping during concurrent exploratory or vascular control laparotomy is frequently required. Stabilization of unstable pelvic fractures is then performed, followed by debridement and irrigation of all wounds, which should be left open, and subsequent provisional stabilization of long bone fractures. The goal of the initial surgical resuscitative endeavor is rapid concurrent control of all sources of hemorrhage to avoid the lethal triad of acidosis, hypothermia and coagulopathy. To this end, multiple surgeons or surgical teams should be utilized whenever feasible. Patients then require ongoing resuscitation followed by early and frequent return to the operating suite throughout the evacuation chain. Utilizing this approach, a high survival rate with reasonable functional outcomes is achievable despite the extreme severity of the DCBI pattern.

En Route Care Provided by US Navy Nurses in Iraq and Afghanistan.

BACKGROUND: US Navy nurses provide en route care for critically injured combat casualties without having a formal program for training, utilization, or evaluation. Little is known about missions supported by Navy nurses. OBJECTIVES: To characterize the number and types of patients transported and skill sets required by Navy nurses during 2 combat support deployments. METHODS: All interfacility casualty transfers between 2 separate facilities in Iraq and Afghanistan were assessed. Number of patients treated, number transported, en route care provider type, transport priority level and duration, injury severity, indication for critical care transport, en route care interventions, and vital signs were evaluated. RESULTS: Of 1550 casualties, 630 required medical evacuation to a higher level of care. Of those, 133 (21%) were transported by a Navy nurse, with 131 (98.5%) classified as "urgent," accounting for 46% of all urgent transports. The primary indication for en route care nursing was mechanical ventilation of intubated patients (97%). Mean (SD) patient transport time was 29.8 (7.9) minutes (range, 17-61 minutes). The most common en route care interventions were administration of intravenous sedation (80%), neuromuscular blockade (79%), and opioids (48%); transfusions (18%); and ventilation changes (11%). No intubations, cricothyroidotomies, chest tube placements, or needle decompressions were performed en route. No deaths occurred during transport. CONCLUSIONS: US Navy nurses successfully transported critically injured patients without observed adverse events. Establishing en route care as a program of record in the Navy will facilitate continuous process improvement to ensure that future casualties receive optimized en route care.

Reexamination of a Battlefield Trauma Golden Hour Policy.

BACKGROUND: Most combat casualties who die, do so in the prehospital setting. Efforts directed toward alleviating prehospital combat trauma death, known as killed in action (KIA) mortality, have the greatest opportunity for eliminating preventable death. METHODS: Four thousand five hundred forty-two military casualties injured in Afghanistan from September 11, 2001, to March 31, 2014, were included in this retrospective analysis to evaluate proposed explanations for observed KIA reduction after a mandate by Secretary of Defense Robert M. Gates that transport of injured service members occur within 60 minutes. Using inverse probability weighting to account for selection bias, data were analyzed using multivariable logistic regression and simulation analysis to estimate the effects of (1) gradual improvement, (2) damage control resuscitation, (3) harm from inadequate resources, (4) change in wound pattern, and (5) transport time on KIA mortality. RESULTS: The effect of gradual improvement measured as a time trend was not significant (adjusted odds ratio [AOR], 0.99; 95% confidence interval [CI], 0.94-1.03; p = 0.58). For casualties with military Injury Severity Score of 25 or higher, the odds of KIA mortality were 83% lower for casualties who needed and received prehospital blood transfusion (AOR, 0.17; 95% CI, 0.06-0.51; p = 0.002); 33% lower for casualties receiving initial treatment by forward surgical teams (AOR, 0.67; 95% CI, 0.58-0.78; p < 0.001); 70%, 74%, and 87% lower for casualties with dominant injuries to head (AOR, 0.30; 95% CI, 0.23-0.38; p < 0.001), abdomen (AOR, 0.26, 95% CI, 0.19-0.36; p < 0.001) and extremities (AOR, 0.13; 95% CI, 0.09-0.17; p < 0.001); 35% lower for casualties categorized with blunt injuries (AOR, 0.65; 95% CI, 0.46-0.92; p = 0.01); and 39% lower for casualties transported within one hour (AOR, 0.61; 95% CI, 0.51-0.74; p < 0.001). Results of simulations in which transport times had not changed after the mandate indicate that KIA mortality would have been 1.4% higher than observed, equating to 135 more KIA deaths (95% CI, 105-164). CONCLUSION: Reduction in KIA mortality is associated with early treatment capabilities, blunt mechanism, select body locations of injury, and rapid transport. LEVEL OF EVIDENCE: Therapy, level III.

Pelvic Fracture Care.

While combat-related pelvis fractures are more commonly open, higher energy, and complex in pattern than those seen in the civilian setting, the principles of management are similar. The primary differences are related to the austere setting in which the initial management takes place, and the lack of resources typically available. Initial management consists of cessation of hemorrhage, along with the multi-disciplinary prioritized management of associated injuries, and skeletal stabilization. This is most commonly achieved with a compressive sheet or pelvic binder, with pelvic external fixation when resources allow, and debridement of open wounds as necessary. Definitive, internal fixation is delayed until the patient arrives at a higher echelon of care.

Amputation: Evaluation and Treatment.

Combat extremity injury and amputation is a life threatening injury. Initial surgical care should focus on hemostasis followed by irrigation and debridement of contaminated and nonviable tissue. Preservation of limb length begins at the initial surgical procedure, to include retention of atypical soft tissue flaps for later reconstruction and treatment of proximal fractures. Serial irrigation and debridements are required throughout the MEDEVAC system as the evolving zone of injury becomes more mature, followed by the appropriate timing of closure outside the combat theater.