[Care for Seriously Injured People in Military Conflicts]. / Schwerstverletztenversorgung in kriegerischen Auseinandersetzungen.

The current war in Ukraine has drawn public attention to the treatment of war injuries. Follow-up treatment in Germany is portrayed the clover leaf of the TraumaNetzwerke DGU, is largely based on the demands of the Federal Ministries for Defence and Health and is intended to enhance resilience in war.The present article presents the special features of the care of severely injured patients during hostilities and should provide insights into the expected results of treatment and the actual procedures. We emphasise the unpredictability of the care of the severely injured during hostilities.On the basis of a search of the literature for the deployment of the German Army in Afghanistan and for the current war in Ukraine, we present the challenges and the typical patterns of injuries. We discuss the factors that can influence the procedures and the quality of the results during hostilities and how these may differ from civil polytrauma care in Germany - which is well established and standardised.Even during deployment of the Federal Army or (as planned) NATO, care of the severely injured is under standardised conditions, as based on the algorithmic ATLS care and which is concentrated on bleeding control. The corresponding equipment and personnel are well established, well prepared and well trained.However, there may be special local conditions or special deployments that make it inevitable that emergency medical care will be more delayed than in the civil system in Germany and can only take place after protracted transport. The objective is always that soldiers in combat should be able to receive medical care that is equivalent to that received by all accident victims in Germany, whatever the time and site of the accident.

A safety and feasibility analysis on the use of cold-stored platelets in combat trauma.

BACKGROUND: Damage-control resuscitation has come full circle, with the use of whole blood and balanced components. Lack of platelet availability may limit effective damage-control resuscitation. Platelets are typically stored and transfused at room temperature and have a short shelf-life, while cold-stored platelets (CSPs) have the advantage of a longer shelf-life. The US military introduced CSPs into the battlefield surgical environment in 2016. This study is a safety analysis for the use of CSPs in battlefield trauma. METHODS: The Department of Defense Trauma Registry and Armed Services Blood Program databases were queried to identify casualties who received room-temperature-stored platelets (RSPs) or both RSPs and CSPs between January 1, 2016, and February 29, 2020. Characteristics of recipients of RSPs and RSPs-CSPs were compared and analyzed. RESULTS: A total of 274 patients were identified; 131 (47.8%) received RSPs and 143 (52.2%) received RSPs-CSPs. The casualties were mostly male (97.1%), similar in age (31.7 years), with a median Injury Severity Score of 22. There was no difference in survival for recipients of RSPs (88.5%) versus RSPs-CSPs (86.7%; p = 0.645). Adverse events were similar between the two cohorts. Blood products received were higher in the RSPs-CSPs cohort compared with the RSPs cohort. The RSPs-CSPs cohort had more massive transfusion (53.5% vs. 33.5%, p = 0.001). A logistic regression model demonstrated that use of RSPs-CSPs was not associated with mortality, with an adjusted odds ratio of 0.96 (p > 0.9; 95% confidence interval, 0.41-2.25). CONCLUSION: In this safety analysis of RSPs-CSPs compared with RSPs in a combat setting, survival was similar between the two groups. Given the safety and logistical feasibility, the results support continued use of CSPs in military environments and further research into how to optimize resuscitation strategies. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

The thin red line: Blood planning factors and the enduring need for a robust military blood system to support combat operations.

ABSTRACT: Battlefield lessons learned are forgotten; the current name for this is the Walker Dip. Blood transfusion and the need for a Department of Defense Blood Program are lessons that have cycled through being learned during wartime, forgotten, and then relearned during the next war. The military will always need a blood program to support combat and contingency operations. Also, blood supply to the battlefield has planning factors that have been consistent over a century. In 2024, it is imperative that we codify these lessons learned. The linchpins of modern combat casualty care are optimal prehospital care, early whole blood transfusion, and forward surgical care. This current opinion comprised of authors from all three military Services, the Joint Trauma System, the Armed Services Blood Program, blood SMEs and the CCC Research Program discuss two vital necessities for a successful military trauma system: (1) the need for an Armed Services Blood Program and (2) Planning factors for current and future deployed military ere is no effective care for wounded soldiers, and by extension there is no effective military medicine.

A trauma expert consensus: Capabilities are required early to improve survivability from traumatic injury.

BACKGROUND: Mortality reviews examine US military fatalities resulting from traumatic injuries during combat operations. These reviews are essential to the evolution of the military trauma system to improve individual, unit, and system-level trauma care delivery and inform trauma system protocols and guidelines. This study identifies specific prehospital and hospital interventions with the potential to provide survival benefits. METHODS: US Special Operations Command fatalities with battle injuries deemed potentially survivable (2001-2021) were extracted from previous mortality reviews. A military trauma review panel consisting of trauma surgeons, forensic pathologists, and prehospital and emergency medicine specialists conducted a methodical review to identify prehospital, hospital, and resuscitation interventions (e.g., laparotomy, blood transfusion) with the potential to have provided a survival benefit. RESULTS: Of 388 US Special Operations Command battle-injured fatalities, 100 were deemed potentially survivable. Of these (median age, 29 years; all male), 76.0% were injured in Afghanistan, and 75% died prehospital. Gunshot wounds were in 62.0%, followed by blast injury (37%), and blunt force injury (1.0%). Most had a Maximum Abbreviated Injury Scale severity classified as 4 (severe) (55.0%) and 5 (critical) (41.0%). The panel recommended 433 interventions (prehospital, 188; hospital, 315). The most recommended prehospital intervention was blood transfusion (95%), followed by finger/tube thoracostomy (47%). The most common hospital recommendations were thoracotomy and definitive vascular repair. Whole blood transfusion was assessed for each fatality: 74% would have required ≥10 U of blood, 20% would have required 5 to 10 U, 1% would have required 1 to 4 U, and 5% would not have required blood products to impact survival. Five may have benefited from a prehospital laparotomy. CONCLUSION: This study systematically identified capabilities needed to provide a survival benefit and examined interventions needed to inform trauma system efforts along the continuum of care. The determination was that blood transfusion and massive transfusion shortly after traumatic injury would impact survival the most. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level V.

Who needs a tourniquet? And who does not? Lessons learned from a review of tourniquet use in the Russo-Ukrainian war.

BACKGROUND: Extremity tourniquets have proven to be lifesaving in both civilian and military settings and should continue to be used by first responders for trauma patients with life-threatening extremity bleeding. This is especially true in combat scenarios in which both the casualty and the first responder may be confronted by the imminent threat of death from hostile fire as the extremity hemorrhage is being treated. Not every extremity wound, however, needs a tourniquet. One of the most important aspects of controlling life-threatening extremity bleeding with tourniquets is to recognize what magnitude of bleeding requires this intervention and what magnitude of bleeding does not. Multiple studies, both military and civilian, have shown that tourniquets are often applied when they are not medically indicated. Overuse of extremity tourniquets has not caused excess morbidity in either the recent conflicts in Iraq and Afghanistan or in the US urban civilian setting. In the presence of prolonged evacuation, however, applying a tourniquet when it is not medically indicated changes tourniquet application from being a lifesaving intervention to one that may cause an avoidable amputation and the development of an array of metabolic derangements and acute kidney injury collectively called prolonged tourniquet application syndrome. METHODS: The recent literature was reviewed for papers that documented the complications of tourniquet use resulting from the prolonged casualty evacuation times being seen in the current Russo-Ukrainian war. The literature was also reviewed for the incidence of tourniquet application that was found to not be medically indicated, in both the US civilian setting and from Ukraine. Finally, an in-person meeting of the US/Ukraine Tourniquet Working Group was held in Warsaw, Poland, in December of 2023. RESULTS: Unnecessary loss of extremities and life-threatening episodes of prolonged tourniquet application syndrome are currently occurring in Ukrainian combat forces because of nonindicated tourniquet use combined with the prolonged evacuation time seen in the Russo-Ukrainian war. Specific numbers of the complications experienced as a result of tourniquet use by Ukrainian forces in the current conflict are treated as classified information and are not available, but multiple sources from the Ukrainian military medical personnel and from the US advisors providing medical assistance to Ukraine have all agreed that the problem is substantial. CONCLUSION: Unnecessary tourniquet morbidity might also occur in US forces in a variety of potential future combat scenarios in which evacuation to surgical care is delayed. Prehospital trauma training programs, including but not limited to tactical combat casualty care, place insufficient emphasis on the need to avoid leaving tourniquets in place when they are not medically indicated. This aspect of training should receive emphasis in future Tactical Combat Casualty Care (TCCC) and civilian first responder curriculum development. An interim ad hoc training solution on this topic is available at the websites noted in this articles. Additional training modalities may follow in the near future. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level V.

Advancing Combat Casualty Care Statistics and Other Battlefield Care Metrics.

Aggregate statistics can provide intra-conflict and inter-conflict mortality comparisons and trends within and between U.S. combat operations. However, capturing individual-level data to evaluate medical and non-medical factors that influence combat casualty mortality has historically proven difficult. The Department of Defense (DoD) Trauma Registry, developed as an integral component of the Joint Trauma System during recent conflicts in Afghanistan and Iraq, has amassed individual-level data that have afforded greater opportunity for a variety of analyses and comparisons. Although aggregate statistics are easily calculated and commonly used across the DoD, other issues that require consideration include the impact of individual medical interventions, non-medical factors, non-battle-injured casualties, and incomplete or missing medical data, especially for prehospital care and forward surgical team care. Needed are novel methods to address these issues in order to provide a clearer interpretation of aggregate statistics and to highlight solutions that will ultimately increase survival and eliminate preventable death on the battlefield. Although many U.S. military combat fatalities sustain injuries deemed non-survivable, survival among these casualties might be improved using primary and secondary prevention strategies that prevent injury or reduce injury severity. The current commentary proposes adjustments to traditional aggregate combat casualty care statistics by integrating statistics from the DoD Military Trauma Mortality Review process as conducted by the Joint Trauma System and Armed Forces Medical Examiner System.

Effectiveness of a specific trauma training on war-related truncal injury management: A pre-post study.

BACKGROUND: Non-Compressible Torso Hemorrhage (NCTH) is the leading cause of preventable death in combat casualty care. To enhance the French military surgeons' preparedness, the French Military Health Service designed the Advanced Course for Deployment Surgery (ACDS) in 2008. This study evaluates behavioral changes in war surgery practice since its implementation. METHODS: Data were extracted from the OPEX® registry, which recorded all surgical activity during deployment from 2003 to 2021. All patients treated in French Role 2 or 3 Medical Treatment Facilities (MTFs) deployed in Afghanistan, Mali, or Chad requiring emergency surgery for NCTH were included. The mechanism of injury, severity, and surgical procedures were noted. Surgical care produced before (Control group) and after the implementation of the ACDS course (ACDS group) were compared. RESULTS: We included 189 trauma patients; 99 in the ACDS group and 90 in the Control group. Most injuries were combat-related (88 % of the ACDS and 82 % of the Control group). The ACDS group had more polytrauma (42% vs. 27 %; p= 0.034) and more e-FAST detailed patients (35% vs. 21 %; p= 0.044). Basics in surgical trauma care were similar between both groups, with a tendency in the ACDS group toward less digestive diversion (n= 6 [6 %] vs. n= 12 [13 %]; p= 0.128), more temporary closure with abdominal packing (n= 17 [17 %] vs. n= 10 [11 %]; p= 0.327), and less re-operation for bleeding (n= 0 [0 %] vs. n= 5 [6 %]; p= 0.046). CONCLUSION: The French model of war trauma course succeeded in keeping specialized surgeons aware of the basics of damage control surgery. The main improvements were better use of preoperative imaging and better management of seriously injured patients.

[Challenge of limb care after violence and war with a special focus on imaging procedures]. / Herausforderung der Extremitätenversorgung nach Gewalt und Krieg mit besonderer Betrachtung bildgebender Verfahren.

BACKGROUND: Injury patterns in the area of the extremities following violence and war harbor many special features and require special attention. Destructive and complex defect injuries are often present, which necessitate elaborate and special reconstruction approaches, predominantly as part of a staged and multistaged procedure. RESEARCH QUESTION: In this context, special attention must be paid to the diagnostic options as an essential aspect, as a clear diagnosis means that targeted treatment steps can be planned and implemented. MATERIAL AND METHOD: The authors' experience in this field from military operations in Afghanistan, Iraq, the Republic of Mali, Kosovo and Georgia, as well as the core content of the Terror and Disaster Surgical Care (TDSC®) course on this topic, have been contextualized and incorporated. In addition, aspects of interdisciplinary cooperation with radiological and, in particular, nuclear medicine disciplines are taken into account in the daily routine. RESULTS AND DISCUSSION: Extremity injuries in the context of violence and war are accompanied by complex bone and surrounding soft tissue defects due to the high energy impact. The principles of reconstruction familiar from everyday life can only be transferred one-to-one to a limited extent. The treatment pathways are often very long and complex and the questions of infection and tissue vitality must be answered again and again in stages. Interdisciplinary collaboration with the disciplines specialized in imaging procedures, particularly in the field of nuclear medicine, is one of the key building blocks for a successful treatment pathway.

[Initial in-hospital treatment of patients with penetrating trauma due to violence and war]. / Innerklinische Erstversorgung von Patienten mit penetrierendem Trauma nach Gewalt und Krieg.

BACKGROUND: Current political and social developments have brought the topics of violence, in this context attributable to terrorism and sabotage, and since February 2022 awareness of war in particular has again greatly increased. This article aims to present the contextualized dealing with penetrating injuries in terms of initial in-hospital treatment. OBJECTIVE: The question remains to be answered as to what extent penetrating injuries require special attention and to what extent the treatment priorities, options and strategies as well as surgical treatment require adaptation of the usual approach in routine clinical practice in Germany. MATERIAL AND METHOD: The experience of the authors in this field from military operations in Afghanistan, Iraq, the Republic of Mali, Kosovo and Georgia as well as the core content of the Terror and Disaster Surgical Care (TDSC®) course on this topic, have been contextualized and incorporated. In addition, aspects of a comprehensive systematic literature review and current data from a national evaluation on the topic of preparing hospitals in Germany for such scenarios are taken into account. RESULTS AND DISCUSSION: The clinical systems need to be well-prepared for such casualties, especially if they require treatment in large numbers. This is precisely so because the majority of patients are in a relevantly threatening situation (usually in the sense of a hemorrhage), treatment must be very urgently provided and in such scenarios a lack of resources must always be overcome, at least temporarily, especially for example for blood transfusions.

Refocusing the Military Health System to support Role 4 definitive care in future large-scale combat operations.

ABSTRACT: The last 20 years of sustained combat operations during the Global War on Terror generated significant advancements in combat casualty care. Improvements in point-of-injury care, en route care, and forward surgical care appropriately aligned with the survival, evacuation, and return to duty needs of the small-scale unconventional conflict. However, casualty numbers in large-scale combat operations have brought into focus the critical need for modernized casualty receiving and convalescence: Role 4 definitive care. Historically, World War II was the most recent conflict in which the United States fought in multiple operational theaters, with hundreds of thousands of combat casualties returned to the continental United States. These numbers necessitated the establishment of a "Zone of the Interior," which integrated military and civilian health care networks for definitive treatment and rehabilitation of casualties. Current security threats demand refocusing and bolstering the Military Health System's definitive care capabilities to maximize its force regeneration capacity in a similar fashion. Medical force generation, medical force sustainment and readiness, and integrated casualty care capabilities are three pillars that must be developed for Military Health System readiness of Role 4 definitive care in future large-scale contingencies against near-peer/peer adversaries.

[Current mortality from war injuries-A narrative review]. / Aktuelle Mortalität von Kriegsverletzungen ­ eine narrative Übersichtsarbeit.

BACKGROUND: The war in Ukraine has led to a strategic reorientation of the German Armed Forces towards national and alliance defense. This has also raised the need for medical and surgical adaptation to scenarios of conventional warfare. In order to develop appropriate and effective concepts it is necessary to identify those war injuries that are associated with a relevant primary and secondary mortality and that can be influenced by medical measures (potentially survivable injuries). OBJECTIVE: The aim of this selective literature review was to identify war injuries with high primary and secondary mortality. METHODS: A selective literature review was performed in the PubMed® database with the search terms war OR combat AND injury AND mortality from 2001 to 2023. Studies including data of war injuries and associated mortality were included. RESULTS: A total of 33 studies were included in the analysis. Severe traumatic brain injury and thoracoabdominal hemorrhage were the main contributors to primary mortality. Injuries to the trunk, neck, traumatic brain injury, and burns were associated with relevant secondary mortality. Among potentially survivable injuries, thoracoabdominal hemorrhage accounted for the largest proportion. Prehospital blood transfusions and short transport times significantly reduced war-associated mortality. CONCLUSION: Control of thoracoabdominal hemorrhage has the highest potential to reduce mortality in modern warfare. Besides that, treatment of traumatic brain injury, burns and neck injuries has a high relevance in reducing mortality. Hospitals of the German Armed Forces need to focus on these requirements.

Blessés de guerres dans un centre de santé de cercle au Mali : profil épidémio-clinique et prise en charge

But : Décrire les aspects épidémiologiques, cliniques et thérapeutiques des blessures de guerres au centre de santé de référence de Douentza. Patients et Méthode : Il s'agissait d'une étude descriptive incluant les patients pris en charge entre le 1er Décembre 2017 et le 31 Décembre 2018 au centre de santé de référence du district sanitaire de Douentza. La stratégie de prise en charge des blessés adoptée était celle de MARCHE et selon les principes de la chirurgie de guerre. Résultats Au total nous avons reçu 71 blessés de guerre au centre de santé de Douentza. Cette série était composée de 66 hommes, de 34 (48%) militaires et représentait 63% des urgences chirurgicales (n=113) et 30% des interventions chirurgicales réalisées dans l'établissement. Les lésions siégeaient sur les membres dans 53% des cas; 23% sur l'abdomen (traumatismes abdominaux pénétrant et/ou perforants) et 15% sur la région dorso-lombaire. Elles étaient causées par des engins explosifs improvisés (48%), des balles (37%) et des armes blanches (15%). Il s'agissait de plaies abdominales dans 11 cas (16%) dont 4 plaies perforantes et 7 plaies non pénétrantes, de plaies vasculaires dans 7 cas (10%), de délabrements cutanéo-musculaires dans 21 cas (30%), de broiements de la main dans 1 cas et d'écrasement également dans 1 cas (1%). Les lésions étaient infectées à l'admission dans 25% des cas et un état de choc était retrouvé chez 15% des patients. 68% des patients étaient référés dans une structure plus équipée pour prise en charge appropriée. L'échographie seul examen para clinique disponible, était utilisée 33 fois (46%) pour explorer l'abdomen. Elle était contributive au diagnostic 11 fois (33%). Sur le plan thérapeutique, le parage chirurgical était d'emblée réalisé chez 53 patients (75%). 16 décès (23%) ont été déplorés, suites à des traumatismes cranio-cérébraux (n=2), plaie cervicale (n=1), péritonites (n=3), polytraumatisme (n=1) et 9 décès ont été constatés à l'admission. Conclusion Les blessés de guerre sont des urgences chirurgicales graves menaçant le pronostic vital immédiat et/ou fonctionnel à long terme. Leur prise en charge exige une organisation et des équipements spécifiques. Le centre de santé de Douentza à l'instar des autres centres de santé du Mali, disposant d'un faible plateau technique et sans plan d'urgence s'est trouvé confronté à l'accueil d'un nombre croissant de blessés de guerre pour lesquels, il n'était pas préparé. La gestion de ces blessés a été difficile d'où la nécessité de repenser les missions des centres de santé de cercle et le niveau de leur plateau technique

Implementación de las recomendaciones del Consenso de Hartford y Tactical Emergency Casualty Care (TECC) en los servicios de emergencia: revisión bibliográfica / Implementation of the Hartford Consensus and Tactical Combat Casualty Care recommendations in emergency services: a review of the literature

Los recientes incidentes con atentados terroristas con tiradores activos o artefactos explosivos improvisados han demostrado que la atención secuencial tradicional produce retrasos en la atención a las víctimas, con resultados no totalmente satisfactorios. La medicina táctica es una nueva herramienta para aplicar en la atención prehospitalaria, que surge de la experiencia en el cuidado a los heridos en zona de combate, aplicando las recomendaciones del Tactical Combat Casualty Care (TCCC). Mediante estas directrices, se trata de disminuir las tres principales causas de muerte prevenible en combate: hemorragia en extremidades, neumotorax a tensión y obstrucción de vía aérea. Para mejorar los índices de supervivencia en incidentes terroristas, es necesario cambiar la forma de atención de los servicios de emergencia. A partir de la experiencia obtenida con el TCCC, el Consenso Hartford y el Comite Tactical Emergency Casualty Care han desarrollado estrategias para mejorar la supervivencia. Ambos desarrollan recomendaciones sobre procedimientos de atención sanitaria dirigidos a primeros intervinientes y a profesionales para su aplicación en entorno hostil (AU)

Recent terrorist attacks involving active shooters or improvised explosive devices have shown that traditionally sequenced emergency management leads to delays in attending victims and suboptimal outcomes. Tactical medicine, a new concept in prehospital care, emerged from experience attending the wounded in combat zones, where the Tactical Combat Casualty Care (TCCC) recommendations are applied. TCCC targets 3 main causes of preventable death in combat: bleeding from extremities, tension pneumothorax, and airway obstruction. A change in the delivery of emergency care during terrorist attacks is now required if we are to improve survival rates. To that end, strategies based on the TCCC and Hartford Consensus recommendations have been developed. Both these approaches describe procedures for both first responders and medical professionals to apply in areas under threat (AU)

Empleo de ácido tranexámico en el herido de combate, experiencia de la sanidad militar española. Serie de casos y revisión de la literatura / Use of tranexamic acid in combat casualties. Experience of the Spanish medical corps. Clinical series and literature review

Objetivo. Describir la experiencia obtenida con el ácido tranexámico (ATX) durante la atención a bajas de combate en el hospital militar español desplegado en Herat (Afganistán) y analizar la bibliografía relacionada en el ámbito militar. Material y métodos. Con la aprobación de las instituciones militares pertinentes, se analizó la administración de ATX en bajas de combate entre marzo y mayo de 2014. De los 745 pacientes atendidos, 10 fueron por arma de fuego/artefacto explosivo (bajas de combate). El método estadístico empleado fue el descriptivo. Para variables categóricas se emplearon frecuencias absolutas y relativas en tanto por ciento (%). Como índices de la tendencia central, la media aritmética y la desviación estándar o la mediana y el rango intercuartílico. Los datos se obtuvieron del registro militar de pacientes atendidos en el hospital militar español de Herat. Resultados. En nuestra serie de datos, todos los pacientes recibieron ATX antes de las 3 primeras horas tras el ataque. La dosis empleada más prevalente fue un gramo iv (intravenoso). La hemorragia fue controlada en el 100% de los casos. Todos los pacientes sobrevivieron y en ninguno se objetivaron efectos secundarios. Estos datos coinciden con lo recomendado en las guías de atención a la baja de combate seguidas por sanidades militares de otros países de nuestro entorno. Conclusión. Todas las bajas en combate fueron tratadas con ATX durante las 3 primeras horas. La dosis más prevalente fue de un gramo iv. La hemorragia fue controlada en la totalidad de los casos. Todos los pacientes sobrevivieron sin efectos secundarios (AU)

Objective. To describe the experience with tranexamic acid (TXA) during the care of combat causalities treated in the Spanish military hospital based in Herat (Afghanistan) and to perform an analysis of the literature related to the military setting. Material and methods. With the approval of the appropriate military institutions, an analysis was performed on the use of TXA in combat casualties treated between March and May 2014. Of the 745 patients seen, 10 were due to a firearm/explosive device (combat casualties). A descriptive analysis was performed on the data collected. Absolute and relative frequencies (%) were used for the categorical variables. For central tendency measurements, the arithmetic mean and standard deviation or the median and interquartile range was calculated. The data were obtained from the military records of patients treated in the Herat military hospital. Results. All the patients in this series received TXA within the first 3 hours after the attack. The most frequent dose used was one gram i.v, with bleeding was controlled in 100% of cases. All the patients survived and none of them had secondary effects. These data agree with that recommended in the combat casualties treatment guide followed by military health in other countries in this setting. Conclusion. All combat casualties were treated with TXA within the first 3 hours. The most frequent dose used was one gram iv and bleeding was controlled in all cases. All the patients survived with no adverse effects being observed (AU)

Cirugía de guerra / No disponible

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