Retrospective Analysis of Long-Term Outcomes After Combat Injury: A Hidden Cost of War.

BACKGROUND: During the conflicts in Iraq and Afghanistan, 52,087 service members have been wounded in combat. The long-term sequelae of these injuries have not been carefully examined. We sought to determine the relation between markers of injury severity and the subsequent development of hypertension, coronary artery disease, diabetes mellitus, and chronic kidney disease. METHODS AND RESULTS: Retrospective cohort study of critically injured US military personnel wounded in Iraq or Afghanistan from February 1, 2002 to February 1, 2011. Patients were then followed until January 18, 2013. Chronic disease outcomes were assessed by International Classification of Diseases, 9th edition codes and causes of death were confirmed by autopsy. From 6011 admissions, records were excluded because of missing data or if they were for an individual's second admission. Patients with a disease diagnosis of interest before the injury date were also excluded, yielding a cohort of 3846 subjects for analysis. After adjustment for other factors, each 5-point increment in the injury severity score was associated with a 6%, 13%, 13%, and 15% increase in incidence rates of hypertension, coronary artery disease, diabetes mellitus, and chronic kidney disease, respectively. Acute kidney injury was associated with a 66% increase in rates of hypertension and nearly 5-fold increase in rates of chronic kidney disease. CONCLUSIONS: In Iraq and Afghanistan veterans, the severity of combat injury was associated with the subsequent development of hypertension, coronary artery disease, diabetes mellitus, and chronic kidney disease.

Diagnosis and management of evacuated casualties with cervical vascular injuries resulting from combat-related explosive blasts.

BACKGROUND: Explosive blasts are common in the modern military environment. These blasts incorporate a concussive component (primary blast injury) and a penetrating component (secondary blast injury). Penetrating injuries are the leading cause of death and injury in these attacks. This review characterizes the vascular injuries associated with penetrating blast injuries to the neck and provides recommendations on the early management of these casualties for the surgeon unfamiliar with these injuries. METHODS: The Landstuhl Regional Medical Center Trauma Registry was queried for admissions from January 1, 2006, to June 30, 2010, coded for a penetrating injury to the neck caused by a blast mechanism. Medical records were abstracted from the patient's initial presentation and care through the deployed military medical system. We recorded the vascular injuries, diagnostic studies, operative events, and early postinjury course for all identified patients. RESULTS: Query of the Landstuhl Regional Medical Center Trauma Registry initially identified 252 patients, of which 53 were excluded because their injuries arose from other mechanisms or were only superficial. Among the remaining 199 patients, 38 (19.1%) sustained 44 vascular injuries requiring treatment. Compelling physical examination findings ("hard signs") were present in 15 (7.5%), who underwent immediate neck exploration. Another 12 patients also underwent neck exploration without any prior imaging studies. Computed tomography (CT) or CT angiography (CTA) examinations were done in 172 patients without hard-sign physical examination findings. Of these, the result of the imaging study was negative in 106 patients, and no further investigation or treatment for cervical vascular trauma was initiated. Of 66 patients who underwent CT/CTA before operative neck exploration, CT/CTA identified a vascular injury in 26 that was later confirmed on neck exploration. The combination of physical examination and CT/CTA resulted in a sensitivity of 96.3% and a specificity of 97.2% in diagnosing cervical vascular injury. CONCLUSIONS: Penetrating cervical wounds from war-related blast trauma are associated with potentially life-threatening vascular injuries. The presenting physical examination, availability of CT/CTA, local surgical expertise, and tactical combat situation all contribute to surgical decision making in these patients. In patients without hard signs of vascular trauma and a normal CT/CTA of the neck, there is no evidence to support mandatory surgical neck explorations or further immediate diagnostic studies to exclude cervical vascular injury.

Feasibility of negative pressure wound therapy during intercontinental aeromedical evacuation of combat casualties.

OBJECTIVE: The objective of this study was to assess the feasibility of utilizing negative pressure wound therapy (NPWT) for the treatment of wartime soft-tissue wounds during intercontinental aeromedical evacuation. BACKGROUND: Attempts to use NPWT during early phases of overseas contingency operations resulted in occasional vacuum system failures and potentially contributed to wound complications. These anecdotal episodes led to a perception that NPWT during aeromedical evacuation carried a high risk of wound complications and limited its use. As a result, NPWT was not frequently applied in the management of soft-tissue wounds before US casualty arrival in the continental United States (CONUS) for wounds sustained in the combat theaters. Concurrently, early NPWT on the traumatic wounds of host nation casualties not requiring aeromedical evacuation seemed to provide many benefits typically associated with the therapy such as decreased infection rates, earlier wound closure, and improved pain management. METHODS: On a daily basis, study investigators reviewed the trauma in-patient census at Landstuhl Regional Medical Center, Germany, to identify patient candidates with soft-tissue extremity or torso wounds that required packing. Patient demographics, injuries, and previous wound treatments were recorded. Surgeons inspected wounds in the operating room and applied a NPWT dressing if deemed appropriate. NPWT was continued throughout the remainder of the patient's hospitalization and also during aeromedical evacuation to CONUS. A study investigator escorted the patient during aeromedical evacuation to educate the flight crews, to record the impact on crew workload, and to troubleshoot the system if necessary. RESULTS: Thirty enrolled patients with 41 separate wounds flew from Germany to CONUS with a portable NPWT system (VAC Freedom System; Kinetic Concepts Incorporated, San Antonio, TX). All 30 patients arrived at the destination facilities with intact and functional systems. No significant in-flight complications were identified, impact on flight crew workload was negligible, and subjective feedback from both flight crews and patients was uniformly positive. For 29 patients, the NPWT dressing was replaced (frequently with serial exchanges) during initial surgical treatment in CONUS; the 30th patient underwent delayed primary closure of his right forearm fasciotomy. Receiving care teams reported no complications attributable to NPWT during aeromedical evacuation. CONCLUSIONS: NPWT is feasible during intercontinental aeromedical evacuation of combat casualties without an increase in wound complications or a significant impact on air crew workload. Further studies are indicated to evaluate the efficacy of NPWT in combat wounds compared with other wound care techniques.

Dismounted Blast Injuries in Patients Treated at a Role 3 Military Hospital in Afghanistan: Patterns of Injury and Mortality.

BACKGROUND: The purposes of this study are to define the pattern of injuries sustained by dismounted troops exposed to improvised explosive devices blasts treated at a Role 3 combat support hospital and to assess injury patterns and mortality associated with the mechanism. Our hypothesis was that mortality is associated with pelvic fracture, massive transfusion, high Injury Severity Score (ISS), multiple limb amputations, and transfer from a Role 2 facility. STUDY DESIGN: Retrospective study of 457 patients. Analysis performed on trauma registry data and systematic review of radiographs. RESULTS: 99.9% were men with a median age of 23 years and median ISS 10. 141 patients (30.9%) required massive blood transfusion. Limb amputations were frequently observed injuries, 109 of 172 amputees (63.4%) had a double amputation. 34 subjects (7.4%) had pelvic fractures; majority of pelvic fractures (88%) were unstable (Tile B or C). Risk factors associated with the overall mortality rate of 1.8% were an ISS greater than 15 (odds ratio: 11.5; 95% confidence interval: 1.38, 533; p = 0.009), need for massive transfusion (p < 0.0001), and the presence of a pelvic fracture (odds ratio: 7.63; 95% confidence interval: 1.13, 41.3; p = 0.018). CONCLUSIONS: Dismounted improvised explosive devices blast injuries result in devastating multiple limb amputations and unstable pelvic fractures, which are associated with mortality after initial trauma resuscitation at a Role 3 hospital.