Combat Operations In Iraq Research Articles

Medical Consequences and Treatment of Injuries Caused by White Phosphorus Munitions

White phosphorus (WP) has been used in hand grenades, mortar and artillery shells, and aerial bombs since World War I. Recently it has been used in combat operations in Iraq, Syria, Afghanistan, Yemen, Nagorno-Karabakh and is used during the Palestinian-Israeli conflict in Gaza. Burns caused by WP usually result in death or disability. The purpose of the work is to analyze and summarize the data of the scientific literature on the medical consequences and treatment of lesions caused using ammunition with WP. Materials and methods. For the analysis, we used available scientific publications describing the consequences of WP burns received during hostilities. The method of analysis is descriptive. The following tasks were solved: the properties of WP as a damaging agent were studied; materials on the medical consequences of WP lesions and methods of treatment of such lesions were summarized. Discussion of the results. WP is highly reactive, highly toxic and ignites in air as early as 35°C. The severity of WP lesions is the result of both the thermal and chemical effects of combustion. Fatalities among humans from WP burns have occurred involving less than 10% of the total body surface area. Burns caused by WP heal more slowly than thermal burns. WP penetrates deeply through the fatty subcutaneous tissue. Therefore, the burns are full-thick, necrotic. The absorbed WP acts as a cellular poison and causes damage to the central nervous system, liver, kidneys, myocardium, and other organs. Any WP particles trapped in the wound may re-ignite. Conclusion. At the pre-hospital stage, the first thing to do is to wash off the wounds with cool water and remove the pieces of WP that have fallen into the skin with forceps. The light from the UV lamp can help to visualize the small particles of WP. Cleaning exfoliated skin and removing visible WP particles from the skin are critical methods for limiting wound severity and systemic WP absorption. It is advisable to excise the burned area within an hour after the lesion and repeat surgical procedures until all phosphorus particles have been removed; to control during the first 48 hours for the content of calcium and phosphorus in the blood serum with appropriate correction. In the future, skin grafting and treatment with allogeneic mesenchymal stem cells are advisable.

Combat events and negative emotions associated with postdeployment illicit drug use among Army National Guard soldiers

ABSTRACT Background and Study Aim One of the major health policy issues for the 1.3 million U.S. military personnel who supported combat operations in Iraq and Afghanistan has been their post deployment adjustment, in particular, reservists after having returned and reverted back to their part-time military service. This study provided preliminary estimates of illicit drug use among deployed reserve military personnel and its relationship to combat exposure. Method Relying on archived survey data, the present study examined illicit drug use among Army National Guard (ARNG) (N = 4,567 in 50 company-sized units) who had been deployed to Iraq in 2010 and returned recently to home station. Results Self-reported illicit drug use was relatively low during post deployment (2.2%) but use was related to specific combat events, such as having seen killed or wounded or having killed and wounded others. Feelings of anger and frustration associated with combat (i.e., experienced trauma, seen wounded or killed, or wounded or killed someone) were predictive of illicit drug use and mediated the relationship of combat events to drug use. Conclusion Findings provide a broader understanding of illicit drug use among veterans and suggest preventive strategies for drug use.

Research Letter: Prevalence of Spine Injuries Among US Military Personnel With Combat-Related Concussion.

To describe the prevalence of spine injuries among US service members with combat-related concussion. A retrospective review of medical records for US service members injured during combat operations in Iraq and Afghanistan between 2002 and 2020. The study sample included 27 897 service members categorized into 3 groups: concussion with loss of consciousness (LOC, n = 4631), concussion non-LOC ( n = 5533), and non-concussion ( n = 17 333). Spine injuries were identified by International Classification of Diseases, Ninth Revision, Clinical Modification ( ICD-9-CM ) codes and classified by body region and nature of injury using the Barell injury diagnosis matrix. Differences in prevalence of spine injuries by concussion group were evaluated using χ 2 tests. Spine injuries were most prevalent among service members with concussion LOC (31.1%), followed by concussion non-LOC (18.3%), and non-concussion (10.0%, P < .001). Sprains and strains were the most prevalent spine injury category, with injuries to the cervical, thoracic, and lumbar regions significantly more prevalent in the concussion groups ( P values < .001), particularly individuals with LOC compared with non-concussion. The US military personnel with combat-related concussion, especially individuals with LOC, may also have spine injuries. Routine assessment for spine injury is recommended during concussion screening because this may impact clinical management and rehabilitation.

Acquisition and retention of military surgical competencies: a survey of surgeons’ experiences in the UK Defence Medical Services

IntroductionThe acquisition and retention of militarily relevant surgical knowledge and skills are vital to enable expert management of combat casualties on operations. Opportunities for skill sustainment have reduced due to...

Health Profiles of Military Women and the Impact of Combat-Related Injury.

The role of women in the United States military is expanding. Women are now authorized to serve in all military occupations, including special operations and frontline combat units, which places them at increased risk of combat exposure and injury. Little is known regarding the impact of these injuries on the health of military women. We conducted a retrospective matched cohort study of women service members who were injured during combat operations in Iraq and Afghanistan. Injured women were individually matched to non-injured controls at a 1:4 ratio. Medical diagnostic codes were abstracted from outpatient encounters in electronic health records, and hierarchical clustering was conducted to identify clusters of diagnostic codes, termed "health profiles." Conditional logistic regression was used to determine whether combat-related injury predicted membership in the profiles. The study sample included 590 injured women and 2360 non-injured controls. Cluster analysis identified six post-deployment health profiles: low morbidity, anxiety/headache, joint disorders, mixed musculoskeletal, pregnancy-related, and multimorbidity. Combat-related injury predicted membership in the anxiety/headache (odds ratio, 1.73; 95% confidence interval, 1.38-2.16) and multimorbidity (odds ratio, 3.43; 95% confidence interval, 2.65-4.43) profiles. Combat-related injury is associated with adverse post-deployment health profiles among military women, and women with these profiles may experience increased health care burden. As future conflicts will likely see a greater number of women with combat exposure and injury, health outcomes research among military women is paramount for the purposes of medical planning and resource allocation.

How do deployed general surgeons acquire relevant skill sets and competencies and mitigate skill fade?

There are recognised difficulties internationally with acquisition and retention of skills among deployed military general surgeons. These are compounded by reduced trauma workload in non-deployed roles or during low tempo...

United States defence contractors and the future of military operations

ABSTRACTThe United States’ global strategic outlook has shifted markedly since the end of major combat operations in Iraq and Afghanistan. As the United States’ strategic posture shifts, the nature of military operations is simultaneously changing rapidly. Many analysts predict that cyber-operations, autonomous weapons systems, artificial intelligence, and clandestine special forces operations will be central features in future conflicts. Although often overlooked by scholars and policy analysts, defence contractors are integral to the development and implementation of these emerging categories of warfare. This inquiry examines the evolving nature of the American defence industry and the roles corporations play in current theatres of conflict. Surprisingly, rather than becoming less reliant on defence contractors after their much-maligned performance in the wars in Iraq and Afghanistan, American military and intelligence agencies have become more dependent on the private sector as technology becomes increasingly central to warfare.

Does Trauma Heighten the Risk of Hematologic Malignancies? a Retrospective Study of U.S. Combat Veterans

Introduction: Multiple case reports have described lymphomas and plasma cell neoplasms developing after trauma 1-4. It has been hypothesized that trauma-induced inflammation may contribute to the neoplasia, and that the site of trauma may serve as the nidus (locus minoris resistentiae) 1, 5. However, to our knowledge there are no studies demonstrating causality. Traumatic injuries sustained during combat have been linked with higher rates of hypertension, coronary artery disease, diabetes mellitus and chronic kidney disease 6. Whether severe injury also increases the risk of hematologic malignancies is unknown. We hypothesized that combat injured veterans have higher rates of lymphoma and plasma cell dyscrasias than un-injured combat veterans. Methods: This was a retrospective cohort study of US military personnel injured during combat operations in Iraq or Afghanistan from 2002-2015 extracted from the Department of Defense (DoD) Trauma Registry. Patients were excluded if they died in theater, had multiple battle injuries, had pre-existing cancer diagnoses or missing data. A comparator arm of deployed and un-injured Iraq and Afghanistan combat veterans was obtained from the Military Health System Data Repository (MDR) matched for year of birth, branch of service, and sex. Cancer diagnoses were defined using International Classification of Diseases, Ninth Revision (ICD-9) and Tenth Revision (ICD-10) Clinical Modification codes obtained from both the DoD and the Veterans Health Administration through the MDR and the Veterans Informatics and Computing Infrastructure, respectively. Malignancy classifications by ICD codes are demonstrated in Table 1 and broken down into aggressive B-cell lymphomas, indolent B-cell lymphomas, Hodgkin lymphoma, T-cell lymphomas and plasma cell dyscrasias. Statistical analyses were performed with the chi-square test and fisher's exact test. This study was approved by the IRB at David Grant USAF Medical Center. Results: There were 9,654 subjects each in the injured and un-injured cohorts. Baseline demographics are demonstrated in Table 2. The mean age was 26 and most patients were junior enlisted, members of the Army, males, and of non-Hispanic white ethnicity/race. The average post-trauma follow-up time was 5.3 years. Overall rates of aggressive B-cell lymphomas, indolent B-cell lymphomas, Hodgkin lymphoma, T-cell lymphomas and plasma cell dyscrasias were low, as demonstrated in Table 3, and there were no statistically significant differences in incidence rates between the two cohorts. Discussion: Traumatic injuries can activate innate immune responses involving inflammatory cytokines, complement, coagulation and dendritic cells, resulting in a pro-inflammatory state 7. Preclinical studies reveal that such inflammation may hamper T-cell immune-surveillance needed to eradicate malignancy 8. However, in our cohort of severely injured combat veterans, rates of lymphomas and plasma cell dyscrasias were not increased over un-injured combat veterans. Strengths of this study include a well-characterized cohort with a matched comparator arm enabling vigorous examination of the impacts of traumatic injuries on cancer. Limitations include retrospective design and relatively short follow up. It is possible that differences will emerge with longer follow up. Conclusions: Despite critical combat trauma injuries being associated with a heightened risk of multiple chronic comorbidities, they do not appear to heighten the risk of lymphoid or plasma cell neoplasms within the first 5-years. The opinions and assertions expressed herein are those of the authors and do not necessarily reflect the official policy or position of the U.S. Air Force, David Grant USAF Medical Center, the Uniformed Services University or the Department of Defense.

An analysis of the pediatric casualties undergoing massive transfusion in Iraq and Afghanistan

BackgroundExisting data on pediatric massive transfusion as part of trauma resuscitation is limited. We report the characteristics of pediatric casualties associated with undergoing massive transfusion at US military treatment facilities during combat operations in Iraq and Afghanistan. MethodsWe queried the Department of Defense Trauma Registry (DODTR) for all pediatric subjects admitted to US and Coalition fixed-facility hospitals in Iraq and Afghanistan from January 2007 to January 2016. We stratified subjects by Centers for Disease Control age groupings: <1, 1–4, 5–9, 10–14, and 15–17 years. We defined a massive transfusion as 40 mL/kg of total blood products or more. ResultsFrom January 2007 through January 2016 there were 3439 pediatric casualties within the registry, of which 543 (15.7%) met criteria for receiving a massive transfusion. The median age of children undergoing massive transfusion was 9 years (IQR 5–12), male (73.4%), injured in Afghanistan (69.9%) and injured by explosives (60.4%). Compared to other pediatric casualties, subjects undergoing massive transfusion had higher composite injury severity scores (median 17 versus 9), higher incidence of tachycardia (86.8% versus 70.9%), increased incidence of hypotension (31.2% versus 7.5%), and decreased survival to hospital discharge (82.6% versus 91.6%). Specific to body regions, casualties undergoing massive transfusion more frequently had serious injuries to the head/neck (30.0% versus 22.8%), the thorax (22.8% versus 9.9%), abdomen (26.8% versus 6.9%), the extremities (42.1% versus 14.6%), while less frequently had serious injuries to the skin (5.3% versus 8.4%). All findings were significant. ConclusionsFurther research is needed to better translate the lessons learned from pediatric trauma care in the combat setting into the civilian setting in developed countries.Level of evidence: 3

Reconstructing the Face of War.

Ongoing combat operations in Iraq, Afghanistan, and other theaters have led to an increase in high energy craniomaxillofacial (CMF) wounds. These challenging injuries are typically associated with complex tissue deficiencies, evolving areas of necrosis, and bony comminution with bone and ballistic fragment sequestrum. Restoring form and function in these combat-sustained CMF injuries is challenging, and frequently requires local and distant tissue transfers. War injuries are different than the isolated trauma seen in the civilian sector. Donor sites are limited on patients with blast injuries and they may have preferences or functional reasons for the decisions to choose flaps from the available donor sites. A case series of patients who sustained severe combat-related CMF injury and were treated at Walter Reed National Military Medical Center (WRNMMC) is presented. Our study was exempt from Institutional Review Board review, and appropriate written consent was obtained from all patients included in the study for the use of representative clinical images. Four patients treated by the CMF team at Walter Reed National Military Medical Center are presented. In this study, we highlight their surgical management by the CMF team at WRNMMC, detail their postoperative course, and illustrate the outcomes achieved using representative patient clinical images. We also supplement this case series demonstrating military approaches to complex CMF injuries with CMF reconstructive algorithms utilized by the senior author (EDR) in the management of civilian complex avulsive injuries of the upper, mid, and lower face are thoroughly reviewed. While the epidemiology and characteristics of military CMF injuries have been well described, their management remains poorly defined and creates an opportunity for reconstructive principles proven in the civilian sector to be applied in the care of severely wounded service members. The War on Terror marks the first time that microsurgery has been used extensively to reconstruct combat sustained wounds of the CMF region. Our manuscript reviews various options to reconstruct these devastating CMF injuries and emphasizes the need for steady communication between the civilian and military surgical communities to establish the best care for these complex patients.

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

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. 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). 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. 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.

Trends in the incidence of physician-diagnosed posttraumatic stress disorder among active-duty U.S. military personnel between 1999 and 2008

BackgroundThe impact of combat operations in Iraq and Afghanistan on the incidence of post-traumatic stress disorder (PTSD) in military service members has been poorly quantified. The purpose of this study was to examine trends in the incidence rate of physician-diagnosed PTSD in active-duty military personnel between 1999 and 2008.MethodsWe conducted a retrospective cohort study utilizing data extracted from the Defense Medical Surveillance System to identify incident cases of PTSD within the study population. The incidence rate of physician-diagnosed PTSD was the primary outcome of interest. Multivariable Poisson regression was used to analyze the data.ResultsThe overall incidence rate of PTSD among all active-duty US military personnel was 3.84 (95% CI: 3.81, 3.87) cases per 1000 person-years. The adjusted average annual percentage increase in the incidence rate of PTSD prior to the initiation of Operation Iraqi Freedom (OIF) was a modest 5.02% (95% CI: 1.85, 8.29%). Following the initiation of OIF, the average annual percentage increase in the rate of PTSD was 43.03% (95% CI: 40.55, 45.56%). Compared to the baseline period between 1999 and 2002, the incidence rate of PTSD in 2008 was nearly 7 times higher (RR = 6.85, 95% CI: 6.49, 7.24). Significant increases in the incidence rate of PTSD were observed following the initiation of OIF regardless of sex, age, race, marital status, military rank, or branch of military service. Notably, the rate of PTSD among females was 6–7 times higher prior to OIF, but there was no difference by gender by 2008.ConclusionsOverall, these data quantify the significant increase in the incidence rate of PTSD following the initiation of combat operations in Iraq and Afghanistan within the active-duty military population during the study period.

Pediatric Prehospital Intraosseous Access During Combat Operations in Iraq and Afghanistan.

Vascular access in critically ill pediatric patients can be challenging with delays potentially leading to worse outcomes. Intraosseous (IO) access has a low rate of complications and can be utilized to administer lifesaving medications. Combat medics are trained to treat adults but may also be required to treat children in the deployed setting. Vascular access in children can be challenging, especially in a hypovolemic state. There are limited data on prehospital lifesaving interventions in children in the combat setting. We sought to characterize the use of IO access in pediatric patients who sustained trauma in the combat setting. We queried the Department of Defense Trauma Registry for all pediatric patients admitted to fixed-facilities and forward surgical teams in Iraq and Afghanistan from January 2007 to January 2016. Within that population, we searched for all subjects with a documented prehospital IO or intravenous (IV) access obtained. Subjects with both an IO and IV documented were placed into the IO category. We separated subjects by age groupings: younger than 1, 1 to 4, 5 to 9, 10 to 14, and 15 to 17 years. During the study period, there were 3439 subjects 17 years or younger. There were 177 in the IO cohort and 803 in the IV cohort. Most subjects in the IO cohort were in the 10- to 14-year-old age group (35.6%), male (79.1%), located in Afghanistan (95.5%), and injured by explosive (52.0%), with lower survival rates than the IV cohort (68.9% vs 90.7%, P < 0.001). Hemostatic dressing application, tourniquet application, intubation, cardiopulmonary resuscitation, sedative administration, ketamine administration, and paralytic administration were all higher in the IO cohort. Pediatric IO placement in the prehospital setting occurred infrequently. Pediatric subjects receiving an IO had higher injury severity scores and higher mortality rates compared with those who received an IV only. Intraosseous use appears to be used more often in critically ill pediatric subjects.

Catastrophic haemorrhage in military major trauma patients: a retrospective database analysis of haemostatic agents used on the battlefield

ObjectivesCatastrophic haemorrhage is a leading cause of morbidity and mortality in trauma, in both military and civilian settings. There are numerous studies looking at the effectiveness of different haemostatic agents...

Using the injury severity score to adjust for comorbid trauma may be double counting burns: implications for burn research

BackgroundThe injury severity score considers burn size and inhalation injury in estimating overall anatomical injury severity. Models that adjust for injury severity score in addition to total burn size and inhalation injury may therefore be double counting the risk from these individual burn characteristics, and obscuring (or overemphasizing) the contribution of risk from each source. The primary aim of this study was to compare differences in the estimated mortality risk of burn trauma using the traditional injury severity score (ISS) calculation and the non-burn injury severity score (NBISS) to examine how separating out the risk attributable to the burn injury versus other trauma changes the interpretation and clinical assessment. MethodsAmong U.S. casualties sustaining burns during combat operations in Iraq and Afghanistan from March 2003 to October 2013, we performed a retrospective cohort study. Unadjusted, adjusted, and weighted Cox proportional hazards models were performed to estimate the risk of age, burn injury severity, and non-burn injury severity on mortality. Weighted hazard ratios and adjusted survival curves were performed using non-parametric inverse probability weighting. ResultsOur final sample consisted of 902 service members with a mortality proportion of 5.7% (n=51). Adjusting for non-burn trauma with traditional ISS attenuated the risk of percent total body surface area burned (%TBSA) by 20% when modeled continuously [HR (95% CI): 1.27 (1.10–1.32) vs. 1.07 (0.99–1.15]. However, the adjusted model using NBISS only attenuated the associated mortality risk of burn size by 5% [HR (95% CI): 1.22 (1.12–1.34)] and had a similar model fit (AIC: 484.2 vs. 478.6). For the weighted Cox proportional hazards models, the risk from a large burn (%TBSA≥60) was also attenuated when adjusting for ISS [HR (95% CI): 2.80 (1.18–6.64)] compared to the model adjusting for NBISS [HR (95% CI): 5.63 (2.79–11.35)]. ConclusionOur analysis comparing the use of traditional ISS and NBISS to measure comorbid non-burn trauma resulted in different interpretations for the effect of %TBSA on subsequent mortality. Our results suggest that the association of %TBSA with death can be obscured by the inclusion of traditional ISS. Therefore, we recommend using NBISS when constructing statistical models in this patient population.

Acquired Stuttering in Veterans of the Wars in Iraq and Afghanistan: The Role of Traumatic Brain Injury, Post-Traumatic Stress Disorder, and Medications.

Determine the association between acquired stuttering (AS), traumatic brain injury (TBI), and post-traumatic stress disorder (PTSD) in a cohort of 309,675 U.S. Iraq and Afghanistan veterans. The secondary aim was to determine the association between AS and medication patterns for veterans in the sample. Retrospective study using data from the Veterans Health Administration National Repository for veterans deployed in support of combat operations in Iraq and Afghanistan and who received Veterans Health Administration care in 2010 and 2011. We identified stuttering using ICD-9 codes to establish the association between AS, TBI, and PTSD, controlling for demographic characteristics and other comorbidities. Multivariable logistic regression was used to determine the association between comorbid conditions and potentially problematic medications associated with stuttering. Two hundred thirty-five veterans (0.08%) were diagnosed with AS in the cohort. There was the greater likelihood of an AS diagnosis for veterans with concomitant TBI and PTSD when compared with veterans without these diagnoses. Over 66% of those with stuttering were prescribed at least one medication that affected speech fluency (antidepressants, anxiolytics, and antiepileptic drugs) compared with 35% of those without AS. Veterans with a comorbid diagnosis of TBI and PTSD were more likely to be diagnosed with AS AOR: 9.77 (95% CI = 6.93-13.78, p < 0.05) and more likely to have been prescribed medications known to affect speech production OR: 3.68 (95% CI = 2.81-4.82, p < 0.05). Clinicians treating veterans with these complex comorbid conditions should consider the impact of medications on speech fluency.

Prehospital Analgesia for Pediatric Trauma Patients in Iraq and Afghanistan

Background: Previous studies have evaluated prehospital analgesia during combat operations in Iraq and Afghanistan, but were limited to the adult population. However, a significant portion of the casualties of those conflicts were children. We describe the prehospital analgesia administered to wartime pediatric trauma patients. Methods: We queried the Department of Defense Trauma Registry (DODTR) for all pediatric patients (<18 years of age) admitted to United States and Coalition fixed-facility hospitals in Iraq and Afghanistan from January 2007 to January 2016. We divided pediatric patients into 2 groups: those that had documentation of receipt of analgesic drugs in the prehospital setting (n = 618) and those who had not received analgesia before reaching a fixed-facility (n = 2,821). For characterization of drug administration, we grouped patients into those receiving acetaminophen, NSAID, fentanyl, ketamine, morphine, or other analgesics (e.g., hydromorphone, tramadol, etc.). Results: During the study period, there were 3,439 pediatric encounters with documentation of 703 instances of analgesia administrations to 618 patients (17.9% of total pediatric encounters). Of the subjects receiving analgesic agents, 46.2% (n = 325) received morphine, 30.4% (n = 214) received fentanyl, 17.4% (n = 122) received ketamine, 1.8% (n = 13) received acetaminophen, and 2.8% (n = 20) received a non-steroidal anti-inflammatory drug. The remaining 9 administrations consisted of methoxyflourane (1), nalbuphine (2), hydromorphone (3), and tramadol (3). An injury severity score (ISS) >15 increased the odds of receiving an analgesic agent (OR 1.26, 95% CI 1.02–1.56). Additionally, there was an association between analgesia administration and the following prehospital interventions: wound dressing, tourniquet, intravenous (IV) line placement, intraosseous line placement, IV fluids, intubation, and external warming. Conclusions: Overall, a low proportion of pediatric trauma subjects within this population received analgesia in the prehospital environment. The most common analgesic medication administered was morphine. Those receiving analgesic agents had more severe injuries and higher rates of concomitant interventions. These results highlight the potential need for Tactical Combat Casualty Care guidelines specifically providing recommendations for analgesia administration among pediatric patients.

Performance Improvement in Combat Casualty Care

The purpose of this review is to examine the necessity for performance improvement and its application in combat casualty care. The review looks at this from the perspectives of local and system-wide efforts. Performance improvement efforts contributed to the overall improvement in mortality seen during the past 15 years of combat operations in Iraq and Afghanistan. While many efforts started at a local level, they expanded to theater-wide efforts. These efforts became codified in the Joint Trauma System Clinical Practice Guidelines. Recent studies have shown the need for continual examination of the system to assure optimal performance. Performance improvement is an inherent responsibility of those providing combat casualty care. Large, theater-wide efforts have been carried out under the guise of the Joint Trauma System with resultant improvements in both the processes and the outcomes. Local performance improvements remain just as integral and have been come increasingly critical over the past few years.

The pediatric resuscitative thoracotomy during combat operations in Iraq and Afghanistan – A retrospective cohort study

BackgroundCombat zone trauma poses a unique set of challenges and injury patterns not seen in the civilian setting. The role of the pediatric resuscitative thoracotomy in combat zones remains unclear given a paucity of data regarding procedure outcomes in this setting. We compare outcomes among children in traumatic arrest undergoing resuscitative thoracotomy versus cardiopulmonary (CPR) resuscitation only. MethodsWe queried the Department of Defense Trauma Registry (DODTR) from 2007 to 2016 for all pediatric subjects that underwent a resuscitative thoracotomy or CPR in the prehospital or emergency department setting during operations in Iraq or Afghanistan. We removed CPR subjects with mechanisms of injury not matched in the thoracotomy cohort. ResultsDuring the study period, there were 3439 pediatric encounters. We identified 13 subjects who underwent a resuscitative thoracotomy and 66 subjects who underwent CPR without thoracotomy with matching mechanisms of injury. When comparing the two cohorts those in the thoracotomy group had higher median thorax body region scores (median 3 versus 0, p = .001), but a trend towards higher rates of survival to discharge (31% versus 9%, p = .108). The youngest survivor in the thoracotomy cohort was less than 1 year old. ConclusionsWe observed a trend towards higher survival among subjects that underwent a resuscitative thoracotomy survived to hospital discharge compared to subjects undergoing CPR without thoracotomy. The literature will benefit from further data to confirm an association between this procedure and a survival benefit among pediatric subjects in the resource limited setting. Furthermore, improvements in documentation will guide equipping and training providers expected to care for pediatric trauma patients.

Emergency department imaging of pediatric trauma patients during combat operations in Iraq and Afghanistan.

Military hospitals in Iraq and Afghanistan treated children with traumatic injuries during the recent conflicts. Diagnostic imaging is an integral component of trauma management; however, few published data exist on its use in the wartime pediatric population. The authors describe the emergency department (ED) utilization of radiology resources for pediatric trauma patients in Iraq and Afghanistan. We queried the Department of Defense Trauma Registry (DODTR) for all pediatric patients admitted to military fixed-facility hospitals in Iraq and Afghanistan from January 2007 to January 2016. We retrieved ED data on ultrasound (US), radiographic and computed tomography (CT) studies. During the study period, there were 3,439 pediatric encounters, which represented 8.0% of all military hospital trauma admissions. ED providers obtained a total of 12,376 imaging studies on 2,920 (84.9%) children. Of the 12,376 imaging studies, 1,341 (10.8%) were US, 4,868 (39.3%) were radiographic and 6,167 (49.8%) were CT exams. Most children undergoing radiographic evaluation were boys (77.8%) and located in Afghanistan (70.4%), and they sustained penetrating injuries (68.0%). Children who underwent imaging had higher composite injury severity scores in comparison to those who did not undergo imaging (10 versus 9). Military health care providers frequently utilized radiographic studies in the evaluation of pediatric trauma casualties in Iraq and Afghanistan. Deployed military hospitals that treat children would benefit from dedicated pediatric-specific imaging training and protocols.