CDR JOHN P WEI, USN MC MD4th Medical Battalion, 4th MLG

BSRF-12

TRAUMA LESSONS FROM THE BATTLEFIELDS OF

AFGHANISTAN AND IRAQ AND IRAQ

BATTLEFIELD TRAUMA

• Changes in epidemiology of combat injuries in current military conflicts

• Lessons learned from care of trauma victims in Afghanistan and Iraq

• Transfer relevant lessons to civilian medical practice

31%31%

7%7%

5%5%

25%25% 10%10% 9%9%

12%12%

1 %1 %

KIA : CNS injuryKIA : CNS injury

KIA : Airway obstructionKIA : Airway obstruction

KIA : Blast / mutilating KIA : Blast / mutilating traumatrauma

KIA : Tension PTXKIA : Tension PTX

KIA : Torso trauma, not KIA : Torso trauma, not correctablecorrectable

KIA : Torso trauma, KIA : Torso trauma, correctablecorrectable

KIA : Extremity KIA : Extremity exsanguinationexsanguination

DOW : Infection, shock DOW : Infection, shock complicationscomplications

Causes of Death in Causes of Death in Ground CombatGround Combat

(KIA = Killed in Action ; DOW =

Died of Wounds)

31%31%

7%7%

5%5%

25%25% 10%10% 9%9%

12%12%11%%

KIA: CNS injuryKIA: CNS injury

KIA: Airway obstructionKIA: Airway obstruction

KIA: Blast / mutilating KIA: Blast / mutilating traumatrauma

KIA: Tension PTXKIA: Tension PTX

KIA: Torso trauma, not KIA: Torso trauma, not correctablecorrectable

KIA: Torso trauma, KIA: Torso trauma, correctablecorrectable

KIA: Extremity KIA: Extremity exsanguinationexsanguination

DOW: Infection, shock DOW: Infection, shock complicationscomplications

Causes of Death in Causes of Death in Ground CombatGround Combat

Location of Death for Fatally Location of Death for Fatally WoundedWounded

Routine Use of Individual Body Armor (IBA) by the U.S. Military

Current issued U.S. Army IBA

Neck, shoulder, and groin flaps

Use of IBA accounts for the decrease in torso wounds and the increase in the percentage of extremity wounds

Use of polycarbonate protective eyewear

CARE FOR INJURIES IN BODY ARMOR

With no skin penetration, internal injuries can occur from a bullet striking armor

• If hit on chest : lung contusion, rib fracture possible keep patient under observation, repeat chest x-ray at 4 to 6 hours

• If lower chest or abdomen hit : may be spleen or liver contusion or laceration

Kevlar armor impossible to cut with standard trauma scissors

LIFE SAVING FIELD INTERVENTIONS

• Stop external hemorrhage• Extremity tourniquets safe and effective

• Needle decompression of tension pneumothorax in dyspneic patient

• Provide airway in unconscious patient• Nasopharyngeal or oral airway efficacious

CPR ON BATTLEFIELD

• Utility of CPR in field:Utility of CPR in field:• drowningdrowning• hypothermiahypothermia• electrical shockelectrical shock• No benefit with mass casualties No benefit with mass casualties

involving limited resourcesinvolving limited resources

PRIORITIES OF TRAUMA

• Life > priority over sight> limb• Exsanguinating hemorrhage >

priority over airway• Torso injury > priority over limb• Pulseless limb > priority over limb

with pulse• Open fracture > priority over closed

fracture

MEDICAL LESSONS FROM BATTLEFIELD

• Clinical experience in dealing with blast and explosive injuries

• New strategies in treating hemorrhage• Mortality rates lower for the current

conflicts• Survivors of massive multiple trauma

with major deficits

PRIOR U.S. MILITARY MEDICAL EXPERIENCE

Mortality Rates After Wounding :• Revolutionary War : 42 %• World War II : 30 %• Korean War : ~25 %• Vietnam War : ~25 %• Persian Gulf War : ~25 %• Iraq and Afghanistan: < 10 %

CURRENT U.S. MILITARY MEDICAL EXPERIENCE

Medical advances from current conflicts:• Treatment of primary and secondary

blast injury• Use of damage control surgery• Blood and activated clotting factors• Tourniquets• Hemostatic agents and dressings

CASUALTIES FROM IED (Improvised Explosive Devices)

• Predominance of current injuries in Afghanistan

• Severe, multisystem• Multiple limb amputations• Secondary injury from being thrown • Eardrum rupture• Occult injuries: blast lung, bowel rupture,

traumatic head injury

IED BLAST INJURIES

BLAST INJURY MECHANISMS

CATEGORIES OF BLAST INJURIES

• Primary : blast pressure on organs and tissue

• Secondary : injuries from projectiles • Tertiary : blunt trauma from patient

thrown against hard object• Miscellaneous : burns, crush, toxic

inhalations

POTENTIAL INJURIES IN BLAST VICTIM

• Respiratory• Pulmonary hemorrhage• Alveolar-venous fistula air embolism

production• Airway epithelial damage

• Circulatory • Cardiac contusion• Air embolism myocardial ischemia

BLAST LUNG

POTENTIAL INJURIES IN BLAST VICTIM

• Digestive tract• Gastrointestinal hemorrhage or

perforation• Retroperitoneal hemorrhage• Ruptured spleen or liver

• Eye and Orbit• Retinal air embolism• Orbital fracture

POTENTIAL INJURIES IN BLAST VICTIM

• Auditory system• Tympanic membrane rupture• Ossicular fractures• Cochlear damage

POTENTIAL INJURIES IN BLAST VICTIM

• Perform ear exam • If TM rupture obtain chest x-ray, hold

for 8 hour observation• If TM not ruptured, no other symptoms

conditionally exclude other serious primary blast injury

• Pulse oximetry : O2 saturation signals early blast lung before symptoms develop

DAMAGE CONTROL SURGERY

Technique widely used in theaterCentral tenet: avoid “ The Deadly Triad”

• Hypothermia• Coagulopathy• Metabolic acidosis

Mortality and morbidity increases with additional risk factors

DAMAGE CONTROL SURGERY

• Stop the bleeding• Close gastrointestinal leaks• Remove major contaminants• Leave wound open to avoid abdominal

compartment syndrome • Transfer to Intensive Care Unit (ICU)

for further stabilization and resuscitation

DAMAGE CONTROL SURGERY

• Resuscitate in ICU

• Normalize blood pressure

• Normalize body temperature

• Normalize coagulation factors• Return to Operating Room when stable for

definitive surgery

HEMOSTASIS

• International Normalized Ratio (INR) > 1.5 on arrival is predictive of need for massive transfusion

• Thawed fresh frozen plasma (FFP) is best resuscitation fluid in MT

• Optimum ratio of plasma : crystalloid is 1:1 to avoid clotting factor dilution > 50 %

HEMOSTASIS

• Limit crystalloid use in the field :• Overuse can lead to inflammatory, acidotic,

coagulopathy effects

• Hextend (hetastarch) suitable for field use• give 500 cc, repeat once if hemorrhage

• Use fresh whole blood; not available, use one unit of FFP for each unit of banked packed cells

• Early use of cryoprecipitate• Recombinant Factor VIIa (rFVlla)• TXA (transamenic acid) for coagulopathy

HEMOSTASIS

• Tourniquets :• Use for any significant extremity

hemorrhage• No adverse events seen • Use early• Issued to every soldier

• The Combat Application Tourniquet (CAT) can be applied by an injured soldier to himself using only one hand

COMBAT APPLICATION TOURNIQUET

HEMOSTASIS

• Hemostatic dressings :• Avoid coagulopathy : control bleeding

early• Used for non-extremity hemorrhage, but

also in severely mangled limbs• Apply with pressure < 5 minutes, patient

stabilized and evacuated

HEMOSTASIS

• HemCon (chitosan)• Originally as bandage

• Now in roll that can be stuffed into wound• QuikClot (initially available as a powder ;

subsequently marketed in a adherent package)• Very exothermic (up to 147 o F)

• Difficult to debride from wound due to adherence• New Advanced Clotting Sponge (ACS)

• Gauze sack : is easily removed from wound

MEDICATIONS IN FIELD• Medical providers carry oral antibiotics

(gatifloxacin 400 mg per day currently used) and pain meds (Celebrex 200 mg per day and / or acetominophen)

• Cefotetan 2 grams IV or IM for severely injured

SUMMARY• Body armor has changed injury patterns• Tourniquets are lifesaving for exsanguinating

extremity wounds• Early antibiotics in the field are indicated• Fresh whole blood and plasma are best

resuscitation fluids• Damage control surgery is effective for the

massively injured• Blast victims have multiple, occult, and delayed

injuries