Severe Multiple Trauma Research Articles

Value of critical care medicine scoring systems and procalcitonin in evaluation of severe multiple trauma

Objective To compare the value of acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ ),sequential organ failure assessment (SOFA) and procalcitonin (PCT) in assessment of severe multiple trauma. Methods A retrospective study was carried out on clinical data of patients with severe multiple trauma who were admitted to ICU from July 1 st 2010 to October 31 st 2011.PCT detection,APECHE Ⅱ and SOFA scoring were routinely performed for all the patients within 24 hours,and were performed again one week later for the patients who were complicated with sepsis within one week.Results The score of APACHE Ⅱ and SOFA in septic shock group was higher than that in severe septic and septic groups (P ＜0.01 ),while PCT level among septic,severe septic and septic shock groups had no statistical difference (P ＞ 0.05).To determine the predicting accuracy of APECHE Ⅱ score,SOFA score and PCT,receiver operating characteristic curve (ROC) was constructed.The areas under the curve (AUC) for APECHE Ⅱ score,SOFA score and PCT in predicting the emergence of sepsis on admission was 0.615,0.663 and 0.160 respectively.AUC for APECHE Ⅱ score,SOFA score and PCT in predicting the occurrence of death among the severe multiple trauma patients on admission was 0.576,0.571 and 0.619 respectively.AUC for APECHE Ⅱ,SOFA and PCT in predicting the death of patients complicated with sepsis at one week after admission was 0.746,0.837 and 0.600 respectively. Conclusions Among the APACHE Ⅱ score,SOFA score and PCT,APACHE Ⅱ and SOFA score are better than PCT in assessing the infection severity of sepsis.SOFA score is the best in predicting the occurrence of sepsis,while PCT is the worst.PCT is the best in predicting the occurrence of death of severe multiple trauma patients,while SOFA score is the worst.SOFA score is better than APACHE Ⅱ score and PCT in predicting the occurrence of death of the patients complicated with sepsis. Key words: Multiple trauma; Sepsis; Research design; Calcitonin

What are Predictors of Mortality in Patients with Pelvic Fractures?

Our knowledge of factors influencing mortality of patients with pelvic ring injuries and the impact of associated injuries is currently based on limited information. We identified the (1) causes and time of death, (2) demography, and (3) pattern and severity of injuries in patients with pelvic ring fractures who did not survive. We prospectively collected data on 5340 patients listed in the German Pelvic Trauma Registry between April 30, 2004 and July 29, 2011; 3034 of 5340 (57%) patients were female. Demographic data and parameters indicating the type and severity of injury were recorded for patients who died in hospital (nonsurvivors) and compared with data of patients who survived (survivors). The median followup was 13 days (range, 0-1117 days). A total of 238 (4%) patients died a median of 2 days after trauma. The main cause of death was massive bleeding (34%), predominantly from the pelvic region (62% of all patients who died because of massive bleeding). Fifty-six percent of nonsurvivors and 43% of survivors were male. Nonsurvivors were characterized by a higher incidence of complex pelvic injuries (32% versus 8%), less isolated pelvic ring fractures (13% versus 49%), lower initial blood hemoglobin concentration (6.7 ± 2.9 versus 9.8 ± 3.0 g/dL) and systolic arterial blood pressure (77 ± 27 versus 106 ± 24 mmHg), and higher injury severity score (ISS) (35 ± 16 versus 15 ± 12). Patients with pelvic fractures who did not survive were characterized by male gender, severe multiple trauma, and major hemorrhage. Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Chapter 15. Analgesics, sedatives, and neuromuscular blockade

Chapter 15. Analgesics, sedatives, and neuromuscular blockade

Late Thoracic Outlet Syndrome after Clavicle Fractures in Patients with Multiple Trauma: A Pitfall of Conservative Treatment

Late thoracic outlet syndrome is a rare complication of clavicle fractures and usually warrants surgical treatment though its cause of clavicle fractures are a common injury and in most cases are treated conservatively. We report a case of a clavicle fracture accompanying severe multiple trauma, which was necessarily treated conservatively because of the severe associated injuries of the patient. The patient was unable to wear a figure-of-8 bandage for the fracture because of the need for complete supine bed rest, due to his other injuries. In this common situation, the clavicle fracture shortened and eventually resulted in the late thoracic outlet syndrome. We believe the cause of this was because a figure-of-8 bandage could not be applied due to the need for complete supine bed rest, and thus was inevitable because of his general condition. This case suggests that the conservative treatment of clavicle fractures, where there is the need for complete bed rest, potentially induces late thoracic outlet syndrome, and that this is indeed a pitfall in the treatment of clavicle fractures in multiple trauma.

Effect of ω-3 polyunsaturated fatty acid on toll-like receptors in patients with severe multiple trauma

This study examined the effects of ω-3 polyunsaturated fatty acid (ω-3PUFA) on the expression of toll-like receptor 2 (TLR2), toll-like receptor 4 (TLR4) and some related inflammatory factors in peripheral blood mononuclear cells (PBMCs) of patients with early-stage severe multiple trauma. Thirty-two patients who were admitted to the Department of Traumatic Surgery, Tongji Hospital (Wuhan, China) between May 2010 and November 2010, and diagnosed as having severe multiple trauma with a injury severity score (ISS) no less than 16, were enrolled in the study and divided into two groups at random (n=16 in each): ω-3PUFA group and control group in which routine parenteral nutrition supplemented with ω-3PUFA or not was administered to the patients in two groups for consecutive 7 days. Peripheral blood from these patients was collected within 2 h of admission (day 0), and 1, 3, 5 and 7 days after the nutritional support. PBMCs were isolated and used for detection of the mRNA and protein expression of TLR2 and TLR4 by using real-time PCR and flow cytometry respectively, the levels of NF-κB by quantum dots-based immunofluorescence assay, the levels of TNF-α, IL-2, IL-6 and COX-2 by ELISA, respectively. The results showed that the mRNA and protein expression of TLR2 and TLR4 in PBMCs was significantly lower in ω-3PUFA group than in control group 5 and 7 days after nutrition support (both P<0.05). The levels of TNF-α, IL-2, IL-6 and COX-2 were found to be substantially decreased in PBMCs in ω-3PUFA group as compared with control group at 5th and 7th day (P<0.05 for all). It was concluded that ω-3PUFA can remarkably decrease the expression of TLR2, TLR4 and some related inflammatory factors in NF-κB signaling pathway in PBMCs of patients with severe multiple trauma, which suggests that ω-3PUFA may suppress the excessive inflammatory response meditated by the TLRs/NF-κB signaling pathway.

Analysis of misdiagnosis in patients with multiple trauma

Objective To explore the features, treatment outcomes and reasons for misdiagnosis in patients with multiple trauma, so as to decrease the incidence of misdiagnosis. Methods A total of 3 163 patients with multiple trauma who were admitted in our department from August 1997 to August 2008, were retrospectively studied to compare the features of diagnosis and treatment. There were 2 117 males (66.93%) and 1 046 females (33.07%) with the mean age of 36.46 years (range, 14-80 years). Parameters such as general status, traumatic condition, diagnosis and treatment situation, prognosis and mortality were analyzed. The differences between misdiagnosis group and correct diagnosis group were compared in terms of severity of injury, complications and treatment outcomes to elucidate the cause and prevention of misdiagnosis. Results The misdiagnosis rate of multiple trauma in this study was 16.19%. The major anatomic sites misdiagnosed were limbs and pelvis (299 positions, 39.50%), abdominal region and pelvic organ (148 positions, 19.55%), and thoracic region (109 positions, 14.40%). In misdiagnosis group, ISS, length of hospital stay, rates of disturbance of consciousness, critical cases and shock cases were 33.78±19.64, (23.59±7.26) days, 49.22%, 33.01% and 47.46%, respectively, which were significantly higher than those of the correct diagnosis group ( P<0.01). And the data showed that the more serious the injury was, the higher the rate of misdiagnosis would be. The rate of primary diagnosis by trauma surgeons in correct diagnosis group was 75.78%, significantly higher than that of the misdiagnosis group ( x 2=382.01, P<0.01). The mortality rate of the misdiagnosis group was 2.93%, which was significantly higher than that for all patients ( x 2= 5.22, P<0.05). Conclusions The results indicated that patients with severe multiple trauma are at high risk of misdiagnosis in early treatment. The mortality rate of misdiagnosed patients is higher than the correctly-diagnosed patients. To prevent misdiagnosis, physicians need to take great care to conduct thorough clinical examinations and repeated evaluation.

Clinical investigation of the prognosis of elderly patients with severe multiple trauma

Clinical investigation of the prognosis of elderly patients with severe multiple trauma

Study on the value of focused abdominal sonography for trauma used by emergency doctor in emergency department

Objective To study the value of focused abdominal sonography for trauma (FAST) used by emergency doctor in emergency department. Method It's a prospective,double-blinded and controlled study from June 2008 to October 2009. A total of 97 casualties with severe multiple trauma, 72 male and 25 female aged from 14 to 88 years old with average age of (41 ± 16) ,admitted to emergency department were enrolled, and the bedside focused abdominal sonography for trauma was performed by emergency doctor. It was diagnosed as positive if free fluid was detected in abdomen or pericardium. The severe injury scores (ISS) were from 14 to 38 with average score of (23.2±9.3). The criteria of inclusion were age over 14 years old, injury happened within 12 hours and casualties admitted directly into emergency room. The criteria of exclusion were death of patients within 2 days without CT scanning of abdomen and exploration of abdomen with laporotomy, and operations directly determined by using FAST without conventinal sonographic examination. The FAST was compared with CT and conventional sonography judged by the findings observed during operation. Results The examination with FAST was completed in (3.18±0.79) min, whereas that with conventional sonography was (16.63t4.62) min(t = 28.61,P ＜0.001). The FAST was positive in 11 cases and negative in 86 cases, whereas the conventional sonography was positive in 13 cases and negative in 84 cases ( P = 0.5). There were 4 false negative findings in FAST resulting in 73% sensitivity, 100% specificity, 95.3% negative predictive value, 4.6% false negative rate, 100% positive predictive value, 0% false positive rate and 95.9% accuracy. Conclusions The emergency doctors are able to operate the FAST well for casualties with multiple trauma in emergency department after proper training. Key words: Multiple trauma; Abdominal trauma; Focused abdominal sonography; Emergency; Hydropericardium; Seroperitoneum; Trauma assessment

Die Damage-control-Strategie

The concept of “damage control” (DC) is a treatment strategy for multiple trauma patients in order to reduce the impact of the initial surgical treatment. The DC concept is well accepted for the surgical control of abdominal bleeding. For the treatment of femoral fractures, primary definitive stabilization should be performed in stable multiple trauma patients. The DC concept seems to be the treatment of choice for patients with severe multiple trauma in an unstable condition and at high risk for developing systemic complications. For multiple trauma patients in an uncertain condition the timing of definitive surgical treatment of major fractures is still being controversially discussed. In these patients, the preoperative condition should be considered carefully when deciding on the type of initial fixation to perform. Anatomical, physiological as well as inflammatory parameters can be used to tailor the amount of surgery that is performed to the clinical condition of the patient.

Mental Health and Posttraumatic Stress Symptoms 2 Years After Severe Multiple Trauma: Self-Reported Disability and Psychosocial Functioning

Soberg HL, Bautz-Holter E, Roise O, Finset A. Mental health and posttraumatic stress symptoms 2 years after severe multiple trauma: self-reported disability and psychosocial functioning. Objectives To describe mental health and posttraumatic stress symptoms (PTSS) for patients with severe multiple trauma at 2 years postinjury. Further, objectives were to examine relationships between PTSS and factors related to the person, injury, and postinjury physical and psychosocial functioning from the time of return home to 2 years after injury. The final aim was to identify predictors of PTSS and mental health at 2 years. Design Prospective cohort study with a 2-year follow-up. Setting Hospital and community setting. Participants Patients (N=99) age 18 to 67 years with multiple trauma and a New Injury Severity Score (NISS) greater than 15 treated at a regional trauma referral center. Mean age ± SD was 35.3±14.2 years; 83% were men. Mean NISS ± SD was 34.9±12.7. Intervention Not applicable. Main Outcome Measures Postinjury psychologic distress associated with depression on the Medical Outcomes Study 36-Item Short-Form Health Survey Mental Health scale and PTSS on the Post-Traumatic Symptom Scale 10 (PTSS-10) at 2 years post injury. Self-reported physical, mental, and cognitive functioning at the return home and 1 and 2 years, and coping strategies. Results Mean PTSS-10 score ± SD at 2 years was 25.6±12.2. Twenty percent had a PTSS-High score, indicating posttraumatic stress disorder (PTSD). Twenty-seven percent had Mental Health scores indicating depression. Predictors of PTSS were sex (female), younger age, avoidant coping, pain, mental health, and cognitive functioning on the return home, which explained 70% of the variance in PTSS-10 score. Conclusions Twenty percent had a PTSS-High score indicating PTSD at 2 years postinjury. The personal factors sex (female), younger age, and avoidant coping and the functional factors pain, mental health, and cognitive functioning predicted PTSS at 2 years.

DNA damage and cell death assessment in patients with severe multiple trauma using comet assay

Purpose: To determine the DNA strand breaks, oxidative DNA damage and cell death in blood and plasma total antioxidant status (TAOS) in 22 patients with severe multiple trauma. Materials and methods: The DNA comet assay was used to measure DNA strand breakage, 8-oxoguanine levels and apoptotic and necrotic nuclei in after admission (day 0) and on days 3, 5, 7 and 15. TAOS was determined by colorimetric method. Results: Trauma patients had high DNA damage at admission (p < 0.01), that further increased with maximum value on day 5 (p < 0.001). On day 15 the degree of DNA damage remained significantly elevated (p < 0.01). No significant difference in the 8-oxoguanine levels at all days examined was found. Patients had a high percentage of apoptotic and necrotic comets at admission, with maximum values on days 3 and 5. A significantly lower TAOS was observed in patients on admission and days 3, 5, 7 and 15 (p < 0.001 in all cases). A decreasing of TAOS on days 7 and 15 compared to that on admission (p < 0.05) was observed. Conclusions: Blood cells from severe trauma patients’ display increased DNA damage associated with apoptosis and necrosis. Reduced plasma TAOS and a tendency to increase of 8-oxoguanine in DNA was observed.

Impact of collection method and sample handling on measured levels of circulating ACTH

Cortisol, which is produced and released by the adrenal gland under the regulation of the adrenocorticotropic hormone (ACTH), plays a crucial role in the survival mechanisms involved in critical illness. A dissociation between high plasma cortisol and low ACTH in patients has been observed in the more chronic phase of critical illness induced by severe sepsis and multiple trauma [1]. In order to assess the potential confounding impact of errors in the measurement of ACTH, we evaluated the stability of ACTH during sample processing.

Traumatic extremity arterial injury in children: Epidemiology, diagnostics, treatment and prognostic value of Mangled Extremity Severity Score

BackgroundTraumatic paediatric arterial injuries are a great challenge due to low incidence and specific characteristics of paediatric anatomy and physiology. The aim of the present study was to investigate their epidemiology, diagnostic and therapeutic options and complications. Furthermore, the prognostic value of the Mangled Extremity Severity Score (MESS) was evaluated.MethodsIn a retrospective clinical study 44 children aged 9.0 ± 3.2 years treated for traumatic extremity arterial lesions in our Level I trauma center between 1971 and 2006 were enrolled. Exclusion criteria were age > 14, venous and iatrogenic vascular injury. Demographic data, mechanism of injury, severity of arterial lesions (by Vollmar and MESS), diagnostic and therapeutic management, complications and outcome were evaluated.ResultsThe most commonly injured vessel was the femoral artery (25%) followed by the brachial artery (22.7%). The mechanism of injury was penetrating (31.8%), isolated severe blunt extremity trauma (29.6%), multiple trauma (25%) and humeral supracondylar fractures (13.6%). In 63.6% no specific vascular diagnostic procedure was performed in favour of emergency surgery. Surgical reconstructive strategies were preferred (68.2%). A MESS < 7 was associated with initial (p < 0.05) and definite limb salvage (p < 0.001) of the lower extremity.ConclusionsTraumatic paediatric vascular injuries are very rare. The most common situations of vascular lesions in childhood were penetrating injuries and fractures of the extremities either as isolated injuries or in multiply injured patients. In paediatric patients, the MESS could serve as a basis for decision making for limb salvage or amputation.

Coagulation management in the treatment of multiple trauma

In recent years a new understanding of trauma-associated hemorrhaging and trauma-induced coagulopathy has been achieved. This coagulopathy is multifactorial with the predominant mechanisms being tissue trauma, shock and hypoperfusion which can lead to hyperfibrinolysis by activation of the endothelium. Routinely tested coagulation parameters, such as prothrombin time and partial thromboplastin time, are frequently employed for decision making but remain problematic as they do not give any information on clot stability, lysis or platelet function. Thrombelastometry seems to be a useful alternative. A pro-active anticipatory approach is required for a successful outcome to be achieved as rescue correction is more difficult than prevention. While the pathophysiological conception of causal relationship of the mentioned therapeutic options is conclusive, an evidence-based validation by randomized controlled studies is mostly lacking. The emergency and anesthesiological concept of damage control resuscitation consists of limiting volume therapy with crystalloids and colloids to reach a mean arterial pressure > or =65 mmHg (higher for head injuries), active (re-)warming management, the prevention of a pH< or =7.2 and a base excess (BE) < or =-6 mmol/l. The early and sufficient application of hemostatic drugs is essential. Because erythrocytes play a substantial role in the coagulation process, hemoglobin (Hb) values of around 6. 2 mmol/l (10 g/dl) and/or a hematocrit of 30% should be strived for when massive non-arrested hemorrhaging occurs. After severe multiple trauma a fibrinogen deficit develops and must be adequately compensated. If coagulation therapy is carried out using fresh frozen plasma sufficient quantities (20-30 ml/kgBW) must be administered to correspondingly raise the coagulation factors. Prothrombin complex concentrates can be helpful to optimize thrombin generation during severe hemorrhaging. Because hyperfibrinolysis occurs more often than previously assumed during severe trauma, an anti-fibrinolytic therapy should be used especially for patients with an instable circulation. The platelet count should not go below 100,000/microl when hemorrhaging occurs after multiple trauma. For thrombocytopathic patients with diffuse bleeding desmopressin (DDAVP) is a therapeutic option and the "off label" use of recombinant activated factor VIIa (rFVIIa) remains an option for individual situations with stringent indications and when the above named measures to optimize the coagulation situation have been taken.

Lyophilized Plasma for Resuscitation in a Swine Model of Severe Injury

Lyophilized plasma (LP) is as safe and effective as fresh frozen plasma (FFP) for resuscitation after severe trauma. Multicenter animal study. Animal laboratories, 2 level I trauma centers. Thirty-two Yorkshire crossbred swine. Lyophilized plasma was analyzed for factor levels and clotting activity before lyophilization and after reconstitution. Swine were subjected to complex multiple trauma including extremity fracture, hemorrhage, severe liver injury, acidosis, and hypothermia. They were then resuscitated with FFP, LP, FFP and packed red blood cells (PRBCs) in a ratio of 1:1, or 1:1 LP and PRBCs. Residual clotting activity of LP after reconstitution, swine mortality, hemodynamic measures, total blood loss, coagulation profiles, and inflammatory measures. Lyophilization decreased clotting factor activity by an average of 14%. Survival and heart rate were similar between all groups. Swine resuscitated with LP had equivalent or higher mean arterial pressures. Swine treated with LP had similar coagulation profiles, plasma lactate levels, and postinjury blood loss compared with those treated with FFP. Swine treated with 1:1 FFP-PRBCs were similar to those treated with 1:1 LP-PRBCs. Resuscitation with LP resulted in a reduction in postresuscitation interleukin 6 expression compared with resuscitation with FFP. The process of lyophilization and reconstitution of plasma reduces coagulation factor activity by 14%, without acute differences in blood loss. Lyophilized plasma can be used for resuscitation in a severe multiple trauma and hemorrhagic shock swine model with efficacy equal to that of FFP and with decreased interleukin 6 production.

Analysis of emergency treatment on severe multiple trauma patients

Objective To study the method of first aid for severe multiple trauma.Methods The emergency data of 236 case of severe multiple trauma were retrospectively analyzed.Results 223 cases were successful rescued and 13 cases died.Conclusions Scientific judgments and rescued of mortal wound were needed for emergency of severe multiple trauma.Patients that were in different serious degree should be prioritized,intensively observed and given effective treatments.Standardized emergency method with strict process could save time for successful first aid and become solid foundation for later treatment and rehabilitation. Key words: Multiple trauma; Emergency; Surgery

Nursing cooperation of prehospital first-aid for patients with cardiac trauma

Objective To summarize the nursing experience in prehospital first-aid of patients with cardiac traumas in order to improve the cooperation capability of prehospital first-aid. Methods The nursing cooperation of prehospital first-aid of 33 patients with cardiac trauma was analyzed retrospec-tively. Results 24 cases of them were rescued successfully, and were completely recovered without se-quelas. 4 cases complicated with severe multiple trauma, died after arriving at hospital, and 3 cases com-plicated with multiple trauma died of complications, while 2 cases with injury of thoracic aorta died during the surgery. Conclusions Early emergency treatment and judgment of traumatic condition could pro-vide valuable chance for inhospital first-aid. Key words: Cardiac trauma; Prehospital first-aid; Nursing cooperation

Early management of complication on severe multiple trauma

Objective To analyze the efficacy of early management of complications in patients with multiple traumas by applying the damage control theory. Method All total of 116 patients admitted to Wuhan Tongji Hospital between Jan 2006 and Jan 2008 were included in this retrospective study and were classified according to treatment method. Overall, 55 cases underwent damage control operations and 61 cases underwent conventional management. The groups of patients were compared in terms of parameters such as length of operation time, time to trsuscitate from shock, lethal triad of death （LTD）, complications and treatment outcomes after operation. Results The length of operation time was （67.43 ± 19.52） min, resuscitation time from shock was （6.77 ± 3.16） h and LTD was （11.54±4.10） h in the damage control group, and （163.95±55.41） min, （22.51 ± 11.65） h and （34.55± 5.63） h, respectively, in the conventional group, with significant differences between the two groups （ P 〈 0.01 ）. The per capita complication and mortality rates were 227.27 % and 3.64 %, respectively, in the damage control group and 363.93% and 9.84%, respectively, in the conventional group （P 〈 0.05）. Conclusions Here, we demonstrated that early management of patients with multiple traumas undergoing operations by applying the damage control theory significantly decreased the operation time, and decreased time to resuscitation from shock and LTD. Furthermore, this approach significantly reduced the incidence of complications and the mortality rate of patients with severe multiple traumas. Key words: Multiple trauma; Damage control; Shock; Lethal triad of death; Complication

The relationship between scapular fractures and concomitant injuries

Objective To study the relationship between the fractured scapular location, the number of fractured scapular regions and the distribution and severity of associated injuries in patients with multiple trauma. Methods One hundred and fifteen consecutive patients with fractured scapula were retrospectively studied between August 2006 and March 2008. There were 96 males and 19 female with an average age of 37.9 years. Mechanism of injury, associated injuries, abbreviated injury soore (AIS) for each part, injury severity score (ISS), and the location and the number of anatomic scapular regions involved in each fracture were studied. Patients were divided into single-region fracture (SRF) group and multiple-region fracture (MRF) group. Furthermore, the SRF group was subdivided into three groups according to their anatomic location: 1) the muscle covered part, 2) the apophyseal part and 3) the glenoid part. Computer tomography and plain radiographs was used for fracture classification in all patients. Results Most scapular fractures were a part of severe multiple trauma, with mean ISS 14.0 among them 42 cases (36.5%) were greater than 16. Road traffic accident was the most common cause for scapular fracture. Ninety-eight patients (85.2%) sustained associated injury. The most frequent part involved was chest(85/115, 73.9%). ISS and AIS for the chest injuries were higher in patients with multiple scapular fractures or scapular fractures in muscle covered part. Conclusion Scapular fractures are usually caused by directly high energy trauma, accompanied by associated injuries. The most frequent region was chest injury. MRF may serve as an external skeletal marker of severe chest injury. Key words: Shoulder fractures; Scapula; Wounds and injuries; Thorax

MS02 WHY MILITARY SURGEONS SAVE MORE LIVES?

The mortality of battle injuries has reduced progressively since World War II (WWII) and is now approximately 10% in the Iraq and Afghanistan war which is at the lowest level ever recorded. This is a remarkable achievement considering the severity of the blast injury and the mass casualty environment. There are many reasons for the reduction in mortality which will be presented. Blast injury results in poly‐trauma with penetrating trauma, blast injury and burns. ‘Blast lung’ and ‘blast brain’ increase the severity of injury and the complexity of management. This severe multiple trauma produces gross physiological compromise and requires trauma care of the highest order in order to save lives and reduce morbidity. The superb trauma system in Iraq has evolved to deliver immediate expert care at the point of injury, rapid road or aero‐medical evacuation (AME), early initial wound (damage control) surgery at a forward operating base, then further resuscitation more specialised damage control surgery at the major field hospital which is a Level 1 Trauma Centre. There have also been advances in critical care and damage control resuscitation and surgical techniques and in the ongoing management of severe burns. When stabilized, the patients are transported with ongoing intensive care to Germany and then to the US. Such severe trauma is infrequently encountered in the civilian sector but there are many lessons in how these casualties are managed in a military trauma system which inform the management of blast injury, poly‐trauma and mass casualties in the civilian sector.