Civilian Trauma Centers Research Articles

The impact of 10 years of war on combat casualty care research

Abstract : October 7, 2011, marked the end of the 10th year of US combat operations in Iraq and Afghanistan. As in previous conflicts, these wars have led to major advances in treating combat casualties, and the advances are also being translated into injury management paradigms in civilian trauma centers. Coincident with these advances was an increase in combat casualty research directed toward identifying new methods for saving lives and reducing the long-term disability resulting from battlefield injuries. A review of the scientific literature published during this period can be used to evaluate the research on combat casualty care conducted during the recent conflicts. One approach for determining the influence of individual articles is to measure the number of citations or the acknowledgments that one article receives from another.6 Previous citation studies have focused on trauma research in general7 and on the vascular surgery literature,8 but to our knowledge, no previous citation analyses have been reported for combat casualty care. The objective of this article was to identify and assess the relative impact of the top 50 most frequently cited articles on combat casualty care published during the first 10 years of war.

Military medical revolution

Abstract : The battlefield has seen tremendous revolutions in military medical affairs (RMMAs) as a result of the last decade of continuous combat operations. The advances in deployed and en route combat casualty care are categorized as individual RMMAs shown in Table 1. As with prehospital advances, the basis for many of the RMMAs in the deployed hospital care environment as well as en route care was translated from civilian trauma practice but is realistic and relevant to the battlefield context. As the conflict evolved, the substantive data from the battlefield led to many new paradigms of treatment and evacuation. The successful implementation of many of these battlefield practices was then effectively translated back into the civilian injury care environment as has been typical of medical advances developed subsequent to previous conflicts of antiquity. The RMMAs that occurred during the last 10 years of combat casualty care are in the realm of deployed hospital care and en route care and are discussed in detail in this article.

Military trauma training at civilian centers

In the late 1990s, a Department of Defense subcommittee screened more than 100 civilian trauma centers according to the number of admissions, percentage of penetrating trauma, and institutional interest in relation to the specific training missions of each of the three service branches. By the end of 2001, the Army started a program at University of Miami/Ryder Trauma Center, the Navy began a similar program at University of Southern California/Los Angeles County Medical Center, and the Air Force initiated three Centers for the Sustainment of Trauma and Readiness Skills (C-STARS) at busy academic medical centers: R. Adams Cowley Shock Trauma Center at the University of Maryland (C-STARS Baltimore), Saint Louis University (C-STARS St. Louis), and The University Hospital/University of Cincinnati (C-STARS Cincinnati). Each center focuses on three key areas, didactic training, state-of-the-art simulation and expeditionary equipment training, as well as actual clinical experience in the acute management of trauma patients. Each is integral to delivering lifesaving combat casualty care in theater. Initially, there were growing pains and the struggle to develop an effective curriculum in a short period. With the foresight of each trauma training center director and a dynamic exchange of information with civilian trauma leaders and frontline war fighters, there has been a continuous evolution and improvement of each center's curriculum. Now, it is clear that the longest military conflict in US history and the first of the 21st century has led to numerous innovations in cutting edge trauma training on a comprehensive array of topics. This report provides an overview of the decade-long evolutionary process in providing the highest-quality medical care for our injured heroes.

“One Front and One Battle”: Civilian Professional Medical Support of Military Surgeons

Although a dedicated corps of full-time active-duty and eserve component military physicians now provide most S battlefield medical and surgical care, the military serices have continued to benefit from close collaborations nd interaction with civilian counterparts. In addition to he individual service and facility-specific relationships ith civilian trauma experts and trauma centers described lsewhere, there has been a concerted effort to establish, aintain, and expand programs that promote professional nteractions and exchange of information between military nd civilian surgeons and surgical leadership. These interactions are not new. The history of civilian rofessional medical support for the military can be traced ack nearly a century. In 1916, foreseeing the possibility hat American involvement in the European hostilities of orld War I might become a reality, The Committee of merican Physicians for Medical Preparedness, chaired by

A Ten Year Review of Civilian Iliac Vessel Injuries from a Single Trauma Centre

ObjectiveTo report the surgical management and outcome of iliac vessel (IV) injuries in a civilian trauma centre with a high incidence of penetrating trauma. Design, patients and methodsA retrospective record review of patients with IV injuries treated between January 2000 and December 2009. ResultsSixty nine patients, 59 with gunshot wounds, sustained 108 iliac vessel injuries. Mean revised trauma and injury severity scores was 7.06 and 28.4, respectively. Twenty nine patients required damage control laparotomy. Common or external iliac arteries were repaired by primary repair (10), temporary shunt with delayed graft (6), interposition graft (5) or ligation if limb non-viable (3). Forty-seven patients had injuries to the common or external iliac vein, 42 were ligated. Mortality was 25% and 6 survivors required amputation. ConclusionsIn a stable patient a primary arterial repair is preferred but a temporary shunt can be a life and limb saving option in the unstable patient. Ligating the common or external iliac veins is associated with a low incidence of prolonged leg swelling.

The Diagnosis of Traumatic Brain Injury on the Battlefield

The conflicts in Iraq and Afghanistan have placed an increased awareness on traumatic brain injury (TBI). Various publications have estimated the incidence of TBI for our deployed servicemen, however all have been based on extrapolations of data sets or subjective evaluations due to our current method of diagnosing a TBI. Therefore it has been difficult to get an accurate rate and severity of deployment related TBIs, or the incidence of multiple TBIs our service members are experiencing. As such, there is a critical need to develop a rapid objective method to diagnose TBI on the battlefield. Because of the austere environment of the combat theater the ideal diagnostic platform faces numerous logistical constraints not encountered in civilian trauma centers. Consequently, a simple blood test to diagnosis TBI represents a viable option for the military. This perspective will provide information on some of the current options for TBI biomarkers, detail concerning battlefield constraints, and a possible acquisition strategy for the military. The end result is a non-invasive TBI diagnostic platform capable of providing much needed advances in objective triage capabilities and improved clinical management of in-Theater TBI.

Resuscitative strategies to maintain homeostasis during damage control surgery

Successful outcome from damage control surgery (DCS) depends as much on elements of resuscitation and non-operative management as on details of the procedure itself. The early management of patients in haemorrhagic shock has undergone substantial revision in the past decade and is now known as 'haemostatic resuscitation'. An updated literature review describing the anaesthetic and resuscitative management of patients with active, ongoing traumatic haemorrhage was distilled to present the current knowledge of the pathophysiology, recommended treatments and areas of active controversy. Current practice in military and civilian trauma centres is described, along with the degree of evidence in support of clinical decisions. Resuscitation of patients with ongoing traumatic haemorrhage has changed substantially in the past two decades. Optimal management now includes deliberate hypotension to minimize blood loss, early use of blood products (especially plasma) and administration of antifibrinolytic therapy. Areas of debate include the role of clotting factor concentrates and depth of anaesthesia. Resuscitation strategies during DCS may be as important as the anatomical repair itself. Recommendations include avoidance of hypothermia, maintenance of a lower than normal blood pressure, and early support of the coagulation system in patients likely to require massive transfusion. Controversies include the optimal ratio of plasma to red blood cells for empirical resuscitation, the ideal role of clotting factor concentrates, and the potential benefit of early, deep anaesthesia. Future research will centre on the complex interaction between the humoral elements of coagulation and the vascular endothelium that regulates perfusion, clotting and integrity of the circulation.

Wartime spine injuries: understanding the improvised explosive device and biophysics of blast trauma

The improvised explosive device (IED) has been the most significant threat by terrorists worldwide. Blast trauma has produced a wide pattern of combat spinal column injuries not commonly experienced in the civilian community. Unfortunately, explosion-related injuries have also become a widespread reality of civilian life throughout the world, and civilian medical providers who are involved in emergency trauma care must be prepared to manage casualties from terrorist attacks using high-energy explosive devices. Treatment decisions for complex spine injuries after blast trauma require special planning, taking into consideration many different factors and the complicated multiple organ system injuries not normally experienced at most civilian trauma centers. Therefore, an understanding about the effects of blast trauma by spine surgeons in the community has become imperative, as the battlefield has been brought closer to home in many countries through domestic terrorism and mass casualty situations, with the lines blurred between military and civilian trauma. We set out to provide the spine surgeon with a brief overview on the use of IEDs for terrorism and the current conflicts in Iraq and Afghanistan and also a perspective on the biophysics of blast trauma.

Evaluation and Management of Peripheral Vascular Injury. Part 1. Western Trauma Association/Critical Decisions in Trauma

This is a position article from members of the Western Trauma Association (WTA). Because there are no prospective randomized trials on the evaluation and management of peripheral vascular trauma, the algorithm (Fig. 1) is based on the expert opinion of WTA members and published observational studies. It may not be applicable at all hospitals caring for injured patients. The algorithm contains letters that correspond to lettered text that is intentionally concise. This Part I algorithm emphasizes evaluation, diagnosis, and need for operation versus a therapeutic procedure performed in interventional radiology, while a Part II algorithm (2011) will focus on operative techniques. Peripheral vascular injures defined as axillobrachial and branches in the upper extremity and femoropopliteal and branches in the lower extremity account for 40% to 75% of all vascular injuries treated in civilian trauma centers.1–4 With the exception of the axillary artery, the long tracks of named arteries and veins in the extremities make them particularly susceptible to either penetrating or blunt trauma. This fact coupled with the smaller diameter of many of these vessels (as compared with those in the thorax or abdomen) and the ability of the patient and others to control external hemorrhage with compression contribute to a low incidence of death in the field.

Trends in trauma transfusion

Trauma is the leading cause of death in young adults and acute blood loss contributes to a large portion of mortality in the early post-trauma period. The recognition of lethal triad of coagulopathy, hypothermia and acidosis has led to the concepts of damage control surgery and resuscitation. Recent experience with managing polytrauma victims from the Iraq and Afghanistan wars has led to a few significant changes in clinical practice. Simultaneously, transfusion practices in the civilian settings have also been extensively studied retrospectively and prospectively in the last decade. Early treatment of coagulopathy with a high ratio of fresh frozen plasma and platelets to packed red blood cells (FFP:platelet:RBC), prevention and early correction of hypothermia and acidosis, monitoring of hemostasis using point of care tests like thromoboelastometry, use of recombinant activated factor VII, antifibrinolytic drugs like tranexamic acid are just some of the emerging trends. Further studies, especially in the civilian trauma centers, are needed to confirm the lessons learned in the military environment. Identification of patients likely to need massive transfusion followed by immediate preventive and therapeutic interventions to prevent the development of coagulopathy could help in reducing the morbidity and mortality associated with uncontrolled hemorrhage in trauma patients.

Trauma Blood Management: Avoiding the Collateral Damage of Trauma Resuscitation Protocols

The use of high ratios of red blood cells to platelets and plasma in trauma resuscitation protocols is quickly gaining favor in civilian trauma centers. The use of higher ratios of coagulation factors to red blood cells has been shown to improve outcomes in both military and civilian centers, but does the evidence support the use of a 1:1:1 ratio, as has been suggested? There is growing evidence that the use of such high ratios may be excessive and potentially harmful, and there has not been enough emphasis on the other components of evidence-based "damage control" resuscitation.

Acute ischemia of the lower limb after injury by gunshot: case report and review of literature.

Civilian and military vascular trauma has evolved dramatically. It is estimated that 80% of all cases of vascular injuries are due to peripheral vascular trauma, most involving the lower extremities. Arterial below-knee injuries by gunshot still remain a challenge, with an associated rate of amputation of 20-54%. This case reports a 48year-old male patient who sustained a gunshot below his left knee. At hospital admission, loss of substance and hemorrhage at the medial and lateral faces of the upper third of his left leg were present with signs of distal ischemia. Arteriography revealed infra-popliteal arterial lesions of the three arterial axes. Two reversed great saphenous vein interposition grafts were performed into the anterior and posterior tibial arteries with immediate revascularization of the left leg and foot. Later, soft tissue reconstruction was accomplished by a split-thickness skin graft. At the fifth month of follow-up, the left leg and foot were viable with good healing, without limitations and with controlled pain. Posterior tibial and dorsalis pedis pulses were palpable. This case report shows the importance of an adequate team approach for treatment of a gunshot extremity injury with vascular lesion. The authors want to highlight the scientific background evidence and the value of comparing worldwide civilian trauma center outcomes, mostly reported previously from the military field.

Can surgery improve neurological function in penetrating spinal injury? A review of the military and civilian literature and treatment recommendations for military neurosurgeons

Penetrating spinal injury (PSI), although an infrequent injury in the civilian population, is not an infrequent injury in military conflicts. Throughout military history, the role of surgery in the treatment of PSI has been controversial. The US is currently involved in 2 military campaigns, the hallmark of both being the widespread use of various explosive devices. The authors reviewed the evidence for or against the use of decompressive laminectomy to treat PSI to provide a triservice (US Army, Navy, and Air Force) consensus and treatment recommendations for military neurosurgeons and spine surgeons. A US National Library of Medicine PubMed database search that identified all literature dealing with acute management of PSI from military conflicts and civilian urban trauma centers in the post-Vietnam War period was undertaken. Nineteen retrospective case series (11 military and 8 civilian) met the study criteria. Eleven military articles covered a 20-year time span that included 782 patients who suffered either gunshot or blast-related projectile wounds. Four papers included sufficient data that analyzed the effectiveness of surgery compared with nonoperative management, 6 papers concluded that surgery was of no benefit, 2 papers indicated that surgery did have a role, and 3 papers made no comment. Eight civilian articles covered a 9-year time span that included 653 patients with spinal gunshot wounds. Two articles lacked any comparative data because of treatment bias. Two papers concluded that decompressive laminectomy had a beneficial role, 1 paper favored the removal of intracanal bullets between T-12 and L-4, and 5 papers indicated that surgery was of no benefit. Based on the authors' military and civilian PubMed literature search, most of the evidence suggests that decompressive laminectomy does not improve neurological function in patients with PSI. However, there are serious methodological shortcomings in both literature groups. For this and other reasons, neurosurgeons from the US Air Force, Army, and Navy collectively believe that decompression should still be considered for any patient with an incomplete neurological injury and continued spinal canal compromise, ideally within 24-48 hours of injury; the patient should be stabilized concurrently if it is believed that the spinal injury is unstable. The authors recognize the highly controversial nature of this topic and hope that this literature review and the proposed treatment recommendations will be a valuable resource for deployed neurosurgeons. Ultimately, the deployed neurosurgeon must make the final treatment decision based on his or her opinion of the literature, individual abilities, and facility resources available.

Selective Non-Operative Management of Ballistic Abdominal Solid Organ Injury in the Deployed Military Setting

This article describes the non-operative management of five patients with ballistic abdominal solid organ injuries in a role 2E medical treatment facility. The selective non-operative management of ballistic abdominal solid...

WARMING A SIMPLE AND CLOSED CIRCULATING FLUID MODEL USING VARIOUS COMBINATIONS OF MILITARY FIELDED HYPOTHERMIA EQUIPMENT

PURPOSE: Hypothermia is very common in the combat casualty and is an independent predictor of mortality in this setting similar to reports from civilian trauma centers. Hypothermia management in the combat zone is largely focused on use of a variety of active and passive external warming methods which have been recommended by the Joint Theater Trauma System. Comprehensive experimental comparison of various combinations of military fielded external warming devices is lacking.

Mass Casualty Tracking with Air Traffic Control Methodologies

An intrahospital casualty throughput system modeled after air traffic control (ATC) tracking procedures was tested in mass casualty exercises. ATC uses a simple tactile process involving informational progress strips representing each aircraft, which are held in bays representing each stage of flight to prioritize and manage aircraft. These strips can be reordered within the bays to indicate a change in priority of aircraft sequence. In this study, a similar system was designed for patient tracking. We compared the ATC model and traditional casualty tracking methods of paper and clipboard in 18 four-hour casualty scenarios, each with 5 to 30 mock casualties. The experimental and control groups were alternated to maximize exposure and minimize training effects. Results were analyzed with Mann-Whitney statistical analysis with p value < 0.05 (two-sided). The ATC method had significantly (p = 0.017) fewer errors in critical patient data (eg, name, social security number, diagnosis). Specifically, the ATC method better tracked the mechanism of injury, working diagnosis, and disposition of patients. The ATC method also performed considerably better with patient accountability during mass casualty scenarios. Data strips were comparable with the control method in terms of ease of use. In addition, participants preferred the ATC method to the control (p = 0.003) and preferred using the ATC method (p = 0.003) to traditional methods in the future. The ATC model more effectively tracked patient data with fewer errors when compared with the clipboard method. Application of these principles can enhance trauma management and can have application in civilian and military trauma centers and emergency rooms.

The use of retrievable inferior vena cava filters in severely injured military trauma patients

Important recent data on retrievable inferior vena cava filter (R-IVCF) used in civilian trauma centers suffer from poor follow-up in these transient patients. Because US military casualties can be more easily followed globally, our objective was to further characterize R-IVCF outcomes in a trauma population with improved follow-up. From July 2003 to June 2007, trauma registry records were retrospectively reviewed for US soldiers injured in Iraq and Afghanistan who had R-IVCF placement. Indications, type of filter, complications, outcomes, and retrieval data were analyzed. Seventy-two R-IVCFs were placed during the study period. Mean follow-up was 28.0 +/- 12.0 months, in 61 (85%) patients. Mean injury severity score (ISS) was 36.3 +/- 10.4 and mean patient age was 27.4 +/- 6.4 years. Fifty-nine R-IVCFs (82%) were not retrieved due to: death (1, 1.3%), technical failure (2, 2.8%), lost to follow-up (11, 15.2%), or contraindications to retrieval (45, 62.5%). Thirteen R-IVCFs were successfully removed, an overall retrieval rate of 18%. Median dwell time of those removed was 47 days (range, 10-94). IVCF indications were prophylactic in 23 (32%) and therapeutic in 49 (68%) cases. Both retrieval failures were due to incorporation into the caval wall, attempted at 90 and 156 days. Deep vein thromboses at the insertion site or pulmonary embolism following R-IVCF placement or removal were not observed. To date, there have been no reports of IVC stenosis or occlusion. R-IVCFs were safely and effectively used in severely injured military trauma patients with high ISS. Despite improved follow-up, overall retrieval remained low, reflecting the civilian experience. Indication, rather than follow-up losses, accounted for the low retrieval rate. Practice patterns for R-IVCF in trauma may need to be re-examined to optimize outcomes.

Early Aggressive Use of Fresh Frozen Plasma Does Not Improve Outcome in Critically Injured Trauma Patients

Recent data from Iraq supporting early aggressive use of fresh frozen plasma (FFP) in a 1:1 ratio to packed red blood cells (PRBCs) has led many civilian trauma centers to adopt this resource intensive strategy. Prospective data were collected on 806 consecutive trauma patients admitted to the intensive care unit over 2 years. Patients were stratified by PRBC:FFP transfusion ratio over the first 24 hours. Stepwise regression models were performed controlling for age, gender, mechanism of injury, injury severity, and acute physiology and chronic health evaluation (APACHE) 2 score to determine if early aggressive use of PRBC:FFP improved outcome. Seventy-seven percent of patients were male (N = 617) and 85% sustained blunt injury (n = 680). Mean age, injury severity score (ISS), and APACHE score were 43 +/- 20 years, 29 +/- 13, and 13 +/- 7, respectively. Mean number of PRBCs and FFP transfused were 7.7 +/- 12 U, 6 U, and 5 +/- 12 U, respectively. Three hundred sixty-five (45%) patients were transfused in the first 24 hours. Sixty-eight percent (n = 250) of them received both PRBCs and FFP. Analyzing these patients by stepwise regression controlling for all significant variables, the PRBC:FFP ratio did not predict intensive care unit days, hospital days, or mortality even in patients who received massive transfusion (> or = 10 U). Furthermore, there was no significant difference in outcome when comparing patients who had a 1:1 PRBC:FFP ratio with those who did not receive any FFP. Early and aggressive use of FFP does not improve outcome after civilian injury. This may reflect inherent differences compared with military injury; however, this practice should be reevaluated.

Critical care medicine at Walter Reed Army Medical Center in support of the global war on terrorism

The military medical experience during wartime is unique and distinct from civilian medical practice. Historically, the military has produced innovations resulting in both civilian and military medical care advances, and our current conflict is no different. In this article, we provide a description of the medical and surgical intensive care units at Walter Reed, their history, and approach to new issues encountered in the care of Operation Iraqi Freedom and Operation Enduring Freedom soldiers. Additionally, descriptive statistics regarding the number of Operation Iraqi Freedom and Operation Enduring Freedom soldiers admitted to the critical care service, basic demographics, general category of injury, and discussion of intensive care unit issues unique to this patient population, such as Acinetobacter and traumatic brain injury, are presented. We intend to provide a general description of our Operation Iraqi Freedom/Operation Enduring Freedom trauma population cared for by the critical care service at Walter Reed Army Medical Center, as well as a discussion of our approach to caring for some of their unique issues, to detail experiences that could translate into improvements for civilian trauma centers.

A Comparison Between Patients Treated at a Combat Support Hospital in Iraq and a Level I Trauma Center in the United States

Combat support hospitals (CSHs) function under adverse operational conditions, delivering care to diverse patients. Appropriate allocation of resources and training are dependent on accurate assessments of the populations' needs. This study compared two patient populations treated between December 2004 and November 2005, one from a CSH in Iraq, the other at a civilian Level I trauma center. The trauma registry at Oregon Health & Science University was queried to evaluate all trauma patients admitted during the study period. The medical databases of the CSH were retrospectively reviewed. Coalition (Co) patients were US soldiers, their allies, and support staff. Noncoalition (Non-Co) patients were Iraqi Army, Iraqi National Guard, enemy forces, and Iraqi civilians. One thousand fifty-four patients were admitted to the CSH. Four hundred sixty-five of 696 (67%) Co patients versus 143 of 358 (40%) Non-Co patients had disease-related diagnoses (p < 0.01). The remaining 446 patients had traumatic diagnoses; 231 (52%) of these were Co patients. The incidence of battle injury was 59% in Co patients versus 90% in Non-Co patients (p < 0.01). One thousand three hundred thirty-nine trauma patients were admitted to Oregon Health & Science University. Civilian patients were older, less likely to be men, and had higher Injury Severity Scale scores than Co and Non-Co patients. Non-Co patients had higher Injury Severity Scale score, longer lengths of stay, and underwent 2.5 times as many operations as Co patients. Of the civilian patients, 93% were injured by blunt mechanisms compared with 20% of combat victims (p < 0.01). Percentages of abdominal, thoracic, and vascular procedures were similar between the three groups, but combat victims had more soft tissue procedures and dressing changes. There were no differences in mortality. Although CSHs and civilian trauma centers treat significantly different patient populations, the operations performed and outcomes are similar. Non-Co patients consumed 2.5 times more operative resources than did Co patients at the CSH.