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.

A Joint Trauma System Clinical Practice Guideline: Traumatic Brain Injury Management and Basic Neurosurgery in the Deployed Environment.

Management of the patient with moderate to severe brain injury in any environment can be time consuming and resource intensive. These challenges are magnified while forward deployed in austere or hostile environments. This Joint Trauma System Clinical Practice Guideline provides recommendations for the treatment and medical management of casualties with moderate to severe head injuries in an environment where personnel, resources, and follow-on care are limited. These guidelines have been developed by acknowledging commonly recognized recommendations for neurosurgical and neuro-critical care patients and augmenting those evaluations and interventions based on the experience of neurosurgeons, trauma surgeons, and intensivists who have delivered care during recent coalition conflicts.

Committee on Surgical Combat Casualty Care position statement: Neurosurgical capability for the optimal management of traumatic brain injury during deployed operations.

BACKGROUND: Experiences over the last three decades of war have demonstrated a high incidence of traumatic brain injury (TBI) resulting in a persistent need for a neurosurgical capability within the deployed theater of operations. Despite this, no doctrinal requirement for a deployed neurosurgical capability exists. Through an iterative process, the Joint Trauma System Committee on Surgical Combat Casualty Care (CoSCCC) developed a position statement to inform medical and nonmedical military leaders about the risks of the lack of a specialized neurosurgical capability. METHODS: The need for deployed neurosurgical capability position statement was identified during the spring 2021 CoSCCC meeting. A triservice working group of experienced forward-deployed caregivers developed a preliminary statement. An extensive iterative review process was then conducted to ensure that the intended messaging was clear to senior medical leaders and operational commanders. To provide additional context and a civilian perspective, statement commentaries were solicited from civilian clinical experts including a recently retired military trauma surgeon boarded in neurocritical care, a trauma surgeon instrumental in developing the Brain Injury Guidelines, a practicing neurosurgeon with world-renowned expertise in TBI, and the chair of the Committee on Trauma. RESULTS: After multiple revisions, the position statement was finalized, and approved by the CoSCCC membership in February 2023. Challenges identified include (1) military neurosurgeon attrition, (2) the lack of a doctrinal neurosurgical capabilities requirement during deployed combat operations, and (3) the need for neurosurgical telemedicine capability and in-theater computed tomography scans to triage TBI casualties requiring neurosurgical care. CONCLUSION: Challenges identified regarding neurosurgical capabilities within the deployed trauma system include military neurosurgeon attrition and the lack of a doctrinal requirement for neurosurgical capability during deployed combat operations. To mitigate risk to the force in a future peer-peer conflict, several evidence-based recommendations are made. The solicited civilian commentaries strengthen these recommendations by putting them into the context of civilian TBI management. This neurosurgical capabilities position statement is intended to be a forcing function and a communication tool to inform operational commanders and military medical leaders on the use of these teams on current and future battlefields. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level V.

Frequency and relevance of acute peritraumatic pulmonary thrombus diagnosed by computed tomographic imaging in combat casualties.

BACKGROUND: Posttraumatic pulmonary embolism is historically diagnosed after clinical deterioration within the first week after injury. An increasing prevalence of immediate and asymptomatic pulmonary embolism have been reported in civilian and military trauma, termed hereafter as acute peritraumatic pulmonary thrombus (APPT). The objective of this study was to define the frequency of APPT diagnosed by computed tomographic (CT) imaging in wartime casualties. An additional objective was to identify factors, which may be associated with this radiographic finding METHODS: A 1-year retrospective cohort analysis conducted using the US and UK Joint Theater Trauma Registries performed to determine the prevalence of and risk factors for the diagnosis of APPT in casualties admitted to Bastion Hospital, Afghanistan. APPT imaging characteristics were collected, and demographics, injury severity and mechanism, and risk factors were included in the analysis. Logistic regression was used to identify factors independently associated with APPT. RESULTS: APPT was found in 66 (9.3%) of 708 consecutive trauma admissions, which received a CT chest with intravenous contrast as part of their initial evaluation. Diagnosis of APPT at the time of injury was made in 23 patients (3.2%), while thrombus was detected in 43 additional patients (6.1%) at the time of reexamination of CT images. Of the APPTs, 47% (n = 31) were central, 38% (n = 25) were segmental, and 15% (n = 10) were subsegmental. Forty-seven percent (n = 31) had bilateral APPT. Logistic regression found presence of deep venous thrombosis on admission (odds ratio, 5.75; 95% confidence interval, 2.44-13.58; p < 0.0001) and traumatic amputation (odds ratio, 2.53; 95% confidence interval, 1.10-5.85; p = 0.030) to be independently associated with APPT. All APPTs were felt to be incidental and likely would not have required interventions such as anticoagulation or vena caval interruption. CONCLUSION: This report is the first to characterize acute, peritraumatic pulmonary thrombus in combat injured. Nearly 1 in 10 patients with severe wartime injury has findings of pulmonary thrombus on CT imaging, although many instances require repeat examination of initial images to identify the clot. APPT is a phenomenon of severe injury and associated with deep venous thrombosis and lower-extremity traumatic amputation. Additional study is needed to characterize the natural history of peritraumatic pulmonary thrombus and the indications for anticoagulation or vena cava filter devices.