August 16, 2011

Study Evaluates Tactical Response Guidelines For Reducing Battlefield Deaths

Implementing a command-directed casualty response system appears to be associated with reducing battlefield casualties, including killed-in-action deaths, casualties who died of wounds, and preventable combat deaths, according to a report in the August issue of Archives of Surgery, one of the JAMA/Archives journals.

"Historically, approximately 90 percent of combat-related deaths occur prior to a casualty reaching a medical treatment facility (MTF)," the authors write as background information in the article. Out-of-hospital care in combat situations is affected by several factors including temperature and extreme weather conditions, limited visual ability during night operations, logistical delays in treatment and evacuation, and lack of specialized medical care. Thus, "a tailored approach to prehospital trauma care must be used when conducting combat operations," the authors write.

Russ S. Kotwal, M.D., M.P.H., with the U.S. Army Special Operations Command, Fort Bragg, N.C., and colleagues examined battlefield survival rates in the 75th Ranger Regiment, U.S. Army Special Operations Command to evaluate a command-directed casualty response system that integrates Tactical Combat Casualty Care (TCCC) guidelines and a prehospital trauma registry. A total of 419 battle injury casualties sustained over seven years of continuous combat in Iraq and 8.5 years in Afghanistan were included in the study. For purposes of the study, a casualty is defined as a member of the 75th Ranger Regiment who sustained a battle injury for which criteria were met for award of the Purple Heart medal.

Stemming from reviews of casualties in World War II, the Korean War and the Vietnam War, TCCC guidelines emphasize three objectives: treat the patient, prevent additional casualties and complete the mission. These guidelines center on preventing the three major, potentially survivable causes of death: extremity hemorrhage exsanguination (severe bleeding), tension pneumothorax (oxygen shortage and low blood pressure due to a collapsed lung, a condition that may progress to cardiac arrest if untreated) and airway obstruction.

Of the 419 casualties identified, 239 (57 percent) were from Operation Iraqi Freedom and 180 (43 percent) were from Operation Enduring Freedom and 387 (92 percent) survived. Injuries resulted from explosions, both improvised explosive device (IED) and non-IED, as well as gunshots, and aircraft and ground vehicle blunt trauma. Non-IEDs were the most frequent cause of injury (43 percent) and more than half of all deaths occurred from gunshot wound injuries.

Although 32 deaths occurred during the study period, no deaths were due to any of the three major potentially survivable causes of death, however one casualty with potentially survivable injuries died of post-surgical complications following evacuation. This death rate (3 percent) is significantly lower than the 24 percent (232 in 982) of potentially survivable deaths previously reported for a subset of U.S. fatalities from Operation Enduring Freedom and Operation Iraqi Freedom.

Lower return-to-duty rates after injuries suggests a higher casualty severity, however the regiment's rates of 10.7 percent killed in action and 1.7 percent who died of wounds were lower than the Department of Defense rates of 16.4 percent and 5.8 percent respectively, for the larger U.S. military population. Additionally, substantial hospital care was provided by nonmedical personnel in this regiment.

"Prehospital advances implemented by TCCC have improved the probability that casualties will arrive at the hospital alive so they can benefit from the trauma care system now in place," the authors conclude. "The remaining challenge is to refine performance improvements and best practices through systemwide prehospital data collection."


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