Search

INTRODUCTION Penetrating cervical carotid artery injury is an uncommon but high-stake scenario associated with stroke and death. The objective of this study was to characterize and compare penetrating carotid injury in the military and civilian setting, as well as provide considerations for management. METHODS Cohorts with penetrating cervical carotid artery injury from the Department of Defense Trauma Registry (2002-2015) and the American Association for the Surgery of Trauma Prospective Observation Vascular Injury Treatment Registry (2012-2018) were analyzed. A least absolute shrinkage and selection operator multivariate analysis using random forest-based imputation was performed to identify risk factors affecting stroke and mortality. RESULTS There were a total of 157 patients included in the study, of which 56 (35.7%) were military and 101 (64.3%) were civilian. The military cohort was more likely to have been managed with open surgery (87.5% vs. 44.6%, p < 0.001) and to have had any procedure to restore or maintain flow to the brain (71.4% vs. 35.6%, p < 0.001), while the civilian cohort was more likely to undergo nonoperative management (45.5% vs. 12.5%, p < 0.001). Stroke rate was higher within the military cohort (41.1% vs. 13.9%, p < 0.001); however, mortality did not differ between the groups (12.5% vs. 17.8%, p = 0.52). On multivariate analysis, predictors for stroke were presence of a battle injury (log odds, 2.1; p < 0.001) and internal or common carotid artery ligation (log odds 1.5, p = 0.009). For mortality outcome, protective factors included a high Glasgow Coma Scale on admission (log odds, -0.21 per point; p < 0.001). Increased admission Injury Severity Score was a predictor of mortality (log odds, 0.05 per point; p = 0.005). CONCLUSION The stroke rate was higher in the military cohort, possibly reflecting complexity of injury; however, there was no difference in mortality between military and civilian patients. For significant injuries, concerted efforts should be made at carotid reconstruction to reduce the occurrence of stroke. LEVEL OF EVIDENCE Retrospective cohort analysis, level III.

Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an emergency procedure that is potentially lifesaving in major noncompressible torso hemorrhage. It may also improve outcome in nontraumatic cardiac arrest. However, the procedure can be technically challenging and requires the immediate presence of a qualified operator. Thus, evidence-based training and assessment of operator skills are essential for successful implementation and patient safety. A prerequisite for this is a valid and reliable assessment tool specific for the procedure. The aim of this study was to develop a tool for assessing procedural competence in REBOA based on best-available knowledge from international experts in the field. Methods We invited international REBOA experts from multiple specialties to participate in an anonymous three-round iterative Delphi study to reach consensus on the design and content of an assessment tool. In round 1, participants suggested items to be included. In rounds 2 and 3, the relevance of each suggested item was evaluated by all participants to reach consensus. Interround data processing was done systematically by a steering group. Results Forty panelists representing both clinical and educational expertise in REBOA from 16 countries (in Europe, Asia, and North and South America) and seven different specialties participated in the study. After 3 Delphi rounds and 532 initial item suggestions, the panelists reached consensus on a 10-item assessment tool with behaviorally anchored rating scales. It includes assessment of teamwork, procedure time, selection and preparation of equipment, puncture technique, guidewire handling, sheath handling, placement of REBOA catheter, occlusion, and evaluation. Conclusion We present the REBOA-RATE assessment tool developed systematically by international experts in the field to optimize content validity. Following further studies of its validity and reliability, this tool represents an important next step in evidence-based training programs in REBOA, for example, using mastery learning. Level of evidence Therapeutic, level V.

This article reviews four emerging endovascular hemorrhage control and extracorporeal perfusion techniques for management of trauma patients with profound hemorrhagic shock including hemorrhage-induced traumatic cardiac arrest: resuscitative endovascular balloon occlusion of the aorta, selective aortic arch perfusion, extracorporeal life support, and emergency preservation and resuscitation. The preclinical and clinical studies underpinning each of these techniques are summarized. We also present an integrated conceptual framework for how these emerging technologies may be used in the future care of trauma patients in both resource-rich and austere environments.

We believe that the rapid and widespread adoption of resuscitative endovascular balloon occlusion of the aorta as well as enthusiasm for catheter-based strategies has led to increased interest in basic endovascular techniques among trauma surgeons. The aim of this article was to describe the most commonly performed endovascular procedures for trauma patients, the basic capital equipment and room set up, and a parsimonious inventory of disposable supplies needed to perform each procedure. Together, these make a standardized trauma-specific endovascular inventory. LEVEL OF EVIDENCE: Economic/decision, level V.

Observational/retrospective/historic controls, level IV.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) for control of noncompressible torso hemorrhage is a technology that is increasingly being utilized in the combat casualty setting. Its use in the resource restricted environment holds potential to improve hemorrhage control, decrease blood product utilization, decrease morbidity, and improve combat mortality. The objective of this report is to present the single largest series of REBOA use on severely injured combat casualties.Over an 18-month period, austere surgical teams comprised of coalition partners provided initial damage control resuscitation (DCR) and surgical stabilization for over 2,300 combat casualties prior to transferring patients to the next level of trauma care.Twenty patients presented with injuries from explosion and gunshot wounds with mean initial heart rate of 129 bpm and mean initial systolic blood pressure of 71 mm Hg. Femoral cutdowns were used in six patients. Aortic occlusion was achieved with REBOA catheter placement in Zone 1 (n = 17) and Zone 3 (n = 2). Systolic blood pressure increased an average of 56 mm Hg with aortic occlusion. There were no access related site complications. All patients survived transport to the next level of care. The majority of blood products transfused in this cohort were whole blood, largely supported by emergent blood drives.This series demonstrates the potential for REBOA as a lifesaving technique for the patient who presents with hemodynamic instability and noncompressible torso hemorrhage. Resuscitative endovascular balloon occlusion of the aorta allows austere surgical teams to rapidly stabilize severely injured combat casualties, expand capability, and provide enhanced DCR while minimizing personnel, resources, and blood product utilization. The use of "whole blood only" strategy for DCR shows potential to be superior to traditional component therapy, and when combined with "proactive" REBOA utilization, provides significant improvements in hemodynamics and hemorrhage control.Case series, level V.

Objective To describe the long-term outcomes of military lower-extremity vascular injuries, and the decision making of surgeons treating these injuries. Background Lower-extremity vascular trauma is an important cause of preventable death and severe disability, and decisions on amputation or limb salvage can be difficult. Additionally, the complexity of the condition is not amenable to controlled study, and there is limited data to guide clinical decision making and establish sensible treatment expectations during rehabilitation. Methods A cohort study of 554 US service members who sustained lower-extremity vascular injury in Iraq or Afghanistan (March 2003 to February 2012) was performed using the military's trauma registry, its electronic health record, patient interviews, and quality-of-life surveys. Long-term surgical and functional outcomes, and the timing and rationale of surgical decisions, were analyzed. Results Of 579 injured extremities, 49 (8.5%) underwent primary amputation and 530 (91.5%) an initial attempt at salvage. Ninety extremities underwent secondary amputation, occurring in the early (n = 60; 30 days) phases after injury. For salvage attempts, freedom from amputation 10 years after injury was 82.7% (79.1%-85.7%). Long-term physical and mental health outcomes were similar between service members who underwent reconstruction and those who underwent amputation. Conclusion This military experience provides data that will inform an array of military and civilian providers who care for patients with severe lower-extremity injury. While the majority salvage attempts endure, success is hindered by ischemia and necrosis during the acute stage and pain, dysfunction and infection in the later phases of recovery. Level of evidence Therapeutic/prognostic, level III.

Background Vascular trauma data have been submitted to the American Association for the Surgery of Trauma PROspective Observational Vascular Injury Trial (PROOVIT) database since 2013. We present data to describe current use of endovascular surgery in vascular trauma. Methods Registry data from March 2013 to December 2016 were reviewed. All trauma patients who had an injury to a named artery, except the forearm and lower leg, were included. Arteries were grouped into anatomic regions and by compressible and noncompressible region for analysis. This review focused on patients with noncompressible transection, partial transection, or flow-limiting defect injuries. Bivariate and multivariate analyses were used to assess the relationships between study variables. Results One thousand one hundred forty-three patients from 22 institutions were included. Median age was 32 years (interquartile range, 23-48) and 76% (n = 871) were male. Mechanisms of injury were 49% (n = 561) blunt, 41% (n = 464) penetrating, and 1.8% (n = 21) of mixed aetiology. Gunshot wounds accounted for 73% (n = 341) of all penetrating injuries. Endovascular techniques were used least often in limb trauma and most commonly in patients with blunt injuries to more than one region. Penetrating wounds to any region were preferentially treated with open surgery (74%, n = 341/459). The most common indication for endovascular treatment was blunt noncompressible torso injuries. These patients had higher Injury Severity Scores and longer associated hospital stays, but required less packed red blood cells, and had lower in hospital mortality than those treated with open surgery. On multivariate analysis, admission low hemoglobin concentration and abdominal injury were independent predictors of mortality. Conclusion Our review of PROOVIT registry data demonstrates a high utilization of endovascular therapy among severely injured blunt trauma patients primarily with noncompressible torso hemorrhage. This is associated with a decreased need for blood transfusion and improved survival despite longer length of stay. Level of evidence Therapeutic/care management, level III.

This issue of the Journal of Trauma and Acute Care Surgery features topics from the 2017 Military Health System Research Symposium and starts a second decade of partnership between the Combat Casualty Care Research Program (CCCRP) and the journal. This publication comes at a time of significant change for the CCCRP, as it responds to military planning for the future multidomain battlefield (MDB). The projected MDB portends markedly different operational scenarios than those conducted over the past 17 years. Emerging threats around the globe have the Department of Defense preparing for more complex battlefields that are larger in size and scope and which pit the United States against better equipped and more sophisticated adversaries. As the CCCRP navigates this new reckoning associated with trauma care on the MDB, its research investments will need to be robust and enabled to plan, program, and budget for agile and closer-term solutions. To accomplish this, the program will need to expand on its strong foundation of lessons learned and assets developed over the past 20 years.

Background Emergent resuscitative endovascular balloon occlusion of the aorta (REBOA) insertion for critically injured patients in hemorrhagic shock is performed blindly with fluoroscopic imaging confirmation. The aim of this study was to determine a reliable method for initial REBOA catheter insertion with balloon deployment between the left subclavian artery takeoff and the celiac trunk (CT). Methods Human cadaver study. External surface (sternal notch, mid-sternum, xiphoid) and intravascular (left subclavian artery [LSA], and CT) landmarks were measured from standardized left and right common femoral artery puncture sites. The landing zone (LZ, distance between LSA and CT) and margins of safety (distance from distal balloon edge to LSA and proximal balloon edge to CT) were calculated using intravascular landmarks. The probability of balloon deployment in the LZ using external landmarks was compared in univariate analysis using the Fisher exact test. Results Ten cadavers were analyzed (seven males; mean body mass index, 19.4 kg/m). Mean (SD) intravascular distances from femoral puncture sites to the LSA and CT were 54.8 (1.9) cm and 32.9 (1.9) cm. The mean (SD) LZ was 21.8 (3.8) cm. Mean (SD) surface distances from femoral puncture sites to the xiphoid, mid-sternum, and sternal notch were 31.8 (3.9) cm, 41.8 (3.3) cm, and 51.8 (3.2) cm. Inserting the catheter to a distance approximated by surface distance from the femoral puncture site to mid-sternum resulted in a 100% likelihood balloon deployment in the LZ for both sides. This was superior to the xiphoid and sternal notch (left site, p = 0.005; right site, p = 0.036; mean of both sites, p = 0.083). Using the mid-sternum landmark, the mean (SD) margins of safety to the LSA and CT were 10.7 (4.3) cm and 3.1 (3.4) cm. Conclusion When using the use of the mid-sternum landmark for REBOA balloon placement, the likelihood of balloon deployment in the LZ was 100% with an acceptable margin of safety.

The duration of use and efficacy of resuscitative endovascular balloon occlusion of the aorta (REBOA) is limited by distal ischemia. We developed a hybrid endovascular-extracorporeal circuit variable aortic control (VAC) device to extend REBOA duration in a lethal model of hemorrhagic shock to serve as an experimental surrogate to further the development of endovascular VAC (EVAC) technologies.Nine Yorkshire-cross swine were anesthetized, instrumented, splenectomized, and subjected to 30% liver amputation. Following a short period of uncontrolled hemorrhage, REBOA was instituted for 20 minutes. Automated variable occlusion in response to changes in proximal mean arterial pressure was applied for the remaining 70 minutes of the intervention phase using the automated extracorporeal circuit. Damage-control surgery and whole blood resuscitation then occurred, and the animals were monitored for a total of 6 hours.Seven animals survived the initial surgical preparation. After 20 minutes of complete REBOA, regulated flow was initiated through the extracorporeal circuit to simulate VAC and provide perfusion to distal tissue beds during the 90-minute intervention phase. Two animals required circuit occlusion for salvage, while five animals tolerated sustained, escalating restoration of distal blood flow before surgical hemorrhage control. Animals tolerating distal flow had preserved renal function, maintained proximal blood pressure, and rapidly weaned from complete REBOA.We combined a novel automated, extracorporeal circuit with complete REBOA to achieve EVAC in a swine model of uncontrolled hemorrhage. Our approach regulated proximal aortic pressure, alleviated supranormal values above the balloon, and provided controlled distal aortic perfusion that reduced ischemia without inducing intolerable bleeding. This experimental model serves as a temporary surrogate to guide future EVAC catheter designs that may provide transformational approaches to hemorrhagic shock.

The Russian military surgeon Nikolai Korotkov is known worldwide, mainly among internists and cardiovascular specialists, as the discoverer of the auscultatory method of measuring arterial blood pressure in 1905. This article reveals him as one of the first military vascular surgeons to carefully investigate, analyze, and register cases of vascular injury during his voluntarily trips to the Russian Far East in 1900 to 1901 and the Russo-Japanese War of 1904 to 1905. Examining 44 patients with extremity arterial and arterial-venous pseudoaneurysms following war-related injury, he routinely performed a measure termed the "arterial pressure index" using "Korotkov sounds." This pioneering approach to assessing extremity perfusion was the precursor to the modern-day ankle-brachial and injured extremity indices, and it initiated the quantitative assessment of the compensatory ability of the vascular system to restore circulation following axial artery ligation. Because of high thrombosis rates following direct vessel repair during his day, he proposed use of pharmacologic substances such as digitalis and amyl nitrite to improve extremity perfusion. As evidence of his innovative nature, Korotkov even proposed the use of "oxygenated nutrient solutions" in the future to improve extremity circulation. More than 100 years after his work, as continuous wave Doppler ultrasound, contrast angiography, and computed tomography are ubiquitous as diagnostic tools, the practice of surgery would be well served to recall Korotkov's foundational work and the rule of thumb for any physician: examine the patient.

Background Attendance by military medical personnel (MMP) at scientific meetings (SMs) of civilian associations has been centrally managed since 2012. We aimed to document the importance of civilian-military interaction to and the impact of this change on combat casualty care (CCC) research. Methods (1) We identified 25 clinically significant CCC articles published by MMP between 2005 and 2014; we determined whether these articles were preceded by presentation by MMP at an SM. (2) We examined the changing civilian-military mix of publications on "damage control resuscitation" (DCR). (3) We analyzed the number of presentations by MMP each year at the American Association for the Surgery of Trauma. (4) We reviewed whether past presidents of the AAST (for 1992-2014) had military experience. Results (1) Ninety-two percent of the CCC articles were previously presented at an SM; 66% were presented at civilian association venues such as AAST. (2) DCR was first described in 2006; the civilian-military mix of publications rose steadily from 0 in 2006 to 80% in 2014. (3) The number of MMP oral presentations at AAST peaked during 2005 to 2007 and has declined to one to two per year since 2012. (4) Thirty-three percent of recent AAST presidents had military experience, versus 100% for the previous era. Conclusion Recent conflicts led to intense civilian-military collaboration in CCC research and to the spread of ideas such as DCR from military to civilian care. However, long-term trends (e.g., declining rates of military service nationally) place such collaboration at risk. Vigorous efforts to foster the vital civilian-military link in CCC are needed.

BACKGROUND There is a need for a prospective registry designed to capture trauma-specific, in-hospital, and long-term outcomes related to vascular injury. METHODS The American Association for the Surgery of Trauma PROspective Vascular Injury Treatment (PROOVIT) registry was used to collect demographic, diagnostic, treatment, and outcome data on vascular injuries. RESULTS A total of 542 injuries from 14 centers (13 American College of Surgeons-verified Level I and 1 American College of Surgeons-verified Level II) have been captured since February 2013. The majority of patients are male (70.5%), with an Injury Severity Score (ISS) of 15 or greater among 32.1%. Penetrating mechanisms account for 36.5%. Arterial injuries to the head/neck (26.7%), thorax (10.4%), abdomen/pelvis (7.8%), upper extremity (18.4%), and lower extremity (26.0%) were identified, along with 98 major venous injuries. Hard signs of vascular injury, including hypotension (systolic blood pressure < 90 mm Hg, 11.8%), were noted in 28.6%. Prehospital tourniquet use for extremity injuries occurred in 20.2% (47 of 233). Diagnostic modalities included exploration (28.8%), computed tomographic angiography (38.9%), duplex ultrasound (3.1%), and angiography (10.7%). Arterial injuries included transection (24.3%), occlusion (17.3%), partial transection/flow limiting defect (24.5%), pseudoaneurysm (9.0%), and other injuries including intimal defects (22.7%). Nonoperative management was undertaken in 276 (50.9%), with failure in 4.0%. Definitive endovascular and open repair were used in 40 (7.4%) and 126 (23.2%) patients, respectively. Damage-control maneuvers were used in 57 (10.5%), including ligation (31, 5.7%) and shunting (14, 2.6%). Reintervention of initial repair was required in 42 (7.7%). Amputation was performed in 7.7% of extremity vascular injuries, and overall hospital mortality was 12.7%. Follow-up ranging from 1 month to 7 months is available for 48 patients via a variety of modalities, with reintervention required in 1 patient. CONCLUSION The PROOVIT registry provides a contemporary picture of the management of vascular injury. This resource promises to provide needed information required to answer questions about optimal diagnosis and management of these patients-including much needed long-term outcome data. LEVEL OF EVIDENCE Epidemiologic study, level V.

The management of hemorrhage shock requires support of central aortic pressure including perfusion to the brain and heart as well as measures to control bleeding. Emerging endovascular techniques including resuscitative endovascular balloon occlusion of the aorta serve as potential lifesaving adjuncts in this setting. The Endovascular Skills for Trauma and Resuscitative Surgery (ESTARS) course was developed to provide fundamental endovascular training for trauma surgeons.ESTARS 2-day course incorporated pretest/posttest examinations, precourse materials, lectures, endovascular and open vascular instruments, Vascular Intervention System Trainer endovascular simulator, and live animal laboratories for training and testing. Curriculum included endovascular techniques for trauma; review of wires, sheaths, and catheters; as well as regional vascular injury management. Animal laboratories integrated arterial access, angiography, coil embolization, resuscitative endovascular balloon occlusion of the aorta, control of iliac artery injury, and vascular shunt placement. Students completed a knowledge test (precourse/postcourse) and a summative skills assessment. The test measured knowledge and judgment in vascular injury management as defined in the course objectives. Vascular Intervention System Trainer and animal laboratory were used for final examinations. Subjective performance was graded by expert observers using a global assessment scale and performance metrics.Four pilot ESTARS courses were completed, with four participants each. Knowledge and performance significantly improved after ESTARS. Mean test examination scores increased by 77% to 85%, with a mean change of 9 percentage points [paired t (15) = 7.82, p0.0001]. The test was unidimensional (Cronbach's α = 0.67). Technical skill significantly improved for both endovascular simulation and live animal laboratory examinations. All participants passed the live animal laboratory practical examination.The ESTARS curriculum is effective at teaching a basic set of endovascular skills for resuscitation and hemorrhage control to trauma surgeons. ESTARS was confirmed as a stepwise and hierarchical curriculum demonstrating measurable improvements in performance metrics and should serve as a model for future competency-based structured training in endovascular trauma skills.

BACKGROUND The Senior Visiting Surgeon (SVS) program at Landstuhl Regional Medical Center (LRMC), Germany, was developed during the wars in Afghanistan and Iraq as a measure to build military-civilian interaction in trauma care and research. The objective of this study was to provide a summary of the program including workload and experiences. An additional objective was to identify factors needed for sustainment of this program during an interwar period. METHODS An electronic, 34-question survey was distributed to 192 surgeons who participated in the SVS program at LRMC, either through the American Association for the Surgery of Trauma or the Society of Vascular Surgery between 2005 and 2012. The survey was composed of multiple-choice and open-ended questions. RESULTS The response rate was 61% (n = 118), with 24% (n = 28) indicating previous military service. These 117 respondents provided 24.5 months of volunteer coverage at LRMC, with 22% (n = 26) performing multiple, 2-week rotations. Visiting surgeons participated in two to five operative cases per week, with the majority of operations related to the management of soft tissue wounds and burns followed by abdominal and vascular procedures, conducted daily multidisciplinary intensive care unit rounds, and collaborated with military surgeons in research projects resulting in 22 publications. More than half (n = 59) of the respondents maintained contact with military colleagues during the 12 months following the rotation. The majority of surveyed surgeons support continuation of the SVS at military facilities in the United States and hosting military surgeons at their civilian trauma center. CONCLUSION This study is the first to quantify the SVS program during the wars in Afghanistan and Iraq. Visiting surgeons provided more than 2 years of combat casualty care during these, the longest wars in US history. Continuation of this program will require expanded military-civilian interaction in trauma care, training, and research during any interwar period.

BACKGROUND: A requirement for improved methods of hemorrhage control and resuscitation along with the translation of endovascular specialty skills has resulted in reappraisal of resuscitative endovascular balloon occlusion of the aorta (REBOA) for end-stage shock. The objective of this report was to describe implementation of REBOA in civilian trauma centers. METHODS: Descriptive case series of REBOA (December 2012 to March 2013) used in scenarios of end-stage hemorrhagic shock at the University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, Maryland, and Herman Memorial Hospital, The Texas Trauma Institute, Houston, Texas. RESULTS: REBOA was performed by trauma and acute care surgeons for blunt (n 4) and penetrating (n 2) mechanisms. Three cases were REBOA in the descending thoracic aorta (Zone I) and three in the infrarenal aorta (Zone III). Mean (SD) systolic blood pressure at the time of REBOA was 59 (27) mm Hg, and mean (SD) base deficit was 13 (5). Arterial access was accomplished using both direct cutdown (n 3) and percutaneous (n 3) access to the common femoral artery. REBOA resulted in a mean (SD) increase in blood pressure of 55 (20)mmHg, and the mean (SD) aortic occlusion time was 18 (34) minutes. There were no REBOA-related complications, and there was no hemorrhage-related mortality. CONCLUSION: REBOA is a feasible and effective means of proactive aortic control for patients in end-stage shock from blunt and penetrating mechanisms. With available technology, this method of resuscitation can be performed by trauma and acute care surgeons who have benefited from instruction on a limited endovascular skill set. Future work should be aimed at devices that allow easy, fluoroscopy-free access and studies to define patients most likely to benefit from this procedure.

BACKGROUND: Hemorrhage is a leading cause of death in military and civilian trauma. Despite the importance of the aorta as a site of hemorrhage control and resuscitative occlusion, detailed knowledge of its morphometry is lacking. The objective of this study was to characterize aortic morphometry in a trauma population, including quantification of distances as well as and diameters and definition of relevant aortic zones. METHODS: Center line measures were made (Volume Viewer) from contrast computed tomography (CT) scans of male trauma patients (18-45 years). Aortic zones were defined based on branch arteries. Zone I includes left subclavian to celiac; Zone II includes celiac to caudal renal; Zone III includes caudal renal to aortic bifurcation. Zone lengths were calculated and correlated to a novel external measure of torso extent (symphysis pubis to sternal notch). RESULTS: Eighty-eight males (mean [SD], 28 [4] years) had CT scans for the study. The median (interquartile range) lengths (mm) of Zones I, II, and III were 210 mm (202-223 mm), 33 mm (28-38 mm), and 97 mm (91-103 mm), respectively. Median aortic diameters at the left subclavian, celiac, and lowest renal arteries were 21 mm (20-23 mm), 18 mm (16-19 mm), and 15 mm (14-16 mm), respectively, and the terminal aortic diameter was 14 mm (13-15 mm). The correlation of determination for descending aortic length (all zones) against torso extend was r = 0.454. CONCLUSION: This study provides a morphometric analysis of the aorta in a male population, demonstrating consistency of length and diameter while defining distinct axial zones. Findings suggest that center line aortic distances correlate with a simple, external measure of torso extent. Morphometric study of the aorta using CT data may facilitate the development and implementation of occlusion techniques to manage noncompressible torso, pelvic, and junctional femoral hemorrhage.

In a letter dated February 5, 1676 (dated 1675 using the Julian calendar), Sir Isaac Newton opined to Robert Hooke, If I have seen further [than you and Descartes], it is by standing on the shoulders of giants. 1 That comment is frequently cited by physicians and surgeons who wish to recognize the debt owed to our predecessors whose efforts have brought us to our present state of enlightenment and understanding of the pathogenesis, diagnosis, and treatment of surgical disease. Many surgical greats were available for selection as the surgical giants for this supplement of the Journal of Trauma and Acute Care Surgery. The four selected giants, whose contributions have had major influence on the organization and delivery of combat casualty care, were involved in wars of the early and mid-19th century (William Beaumont and Jonathan Letterman, respectively) and the twoworldwars of the 20th century (George Crile,World War I, and Edward D. Churchill, World War II) (Fig. 1). Each of the four was an experienced clinical surgeon of his time, and each appreciated the importance of scientific study to advance surgical care and improve patient outcomes.

BACKGROUND: This study aimed to analyze demographic, epidemiologic, temporal, and outcome data from an integrated trauma registry of patients undergoing initial stabilization and transfer within a mature domestic trauma network; compare data with a companion subset from the Department of Defense Trauma Registry. Texas Trauma Service Area-P is composed of 25 counties, 15 rural Level IV trauma centers (no acute care surgery), and two Level I trauma centers. METHODS: This study has a retrospective cohort design. We hypothesize that Injury Severity Scores (ISSs), time intervals, and other clinical indicators would be complimentary to contemporary combat casualties. Inclusion criteria include age 18 years to 80 years, transferred from Level IV to Level I trauma center, or expired en route. RESULTS: A total of 543 subjects (84%) met the criteria and were analyzed. Averages and confidence intervals were as follows: age of 40 years (38Y41 years), males at 81%, ISS of 10 (10Y11), intensive care unit stay of 2 days (1Y3 days), and hospital stay of 5d ays (4Y6 days). Mechanisms of injury were as follows: penetrating (15%), blunt weapon (19%), stabs (9%), burns (5%), and gunshots (5%). Eight percent received blood within the first 24 hours. Survival was at 98%. Time intervals (95% confidence interval) were as follows: prehospital at 1:43 (1:29Y1:58), Level IV dwell time at 3:17 (3:06Y3:28), interfacility transfer at 1:43 (1:36Y1:49), and total at 6:39 (6:20Y6:58). RemTORN cases were older, spent longer time en route to Level I, and had ISS similar to combat casualties. Rates of blood transfusion in the first 24 hours and survival were similar in order of magnitude. CONCLUSION: The RemTORN platform is operational. Demographic, epidemiologic, and temporal characteristics as observed will support clinical investigations of traumatic coagulopathy, shock, and potential interventions before Level I arrival. Results of such investigations will likely be applicable to the contemporary and future battlefield. (J Trauma Acute Care Surg. 2013;75: S164YS168. Copyright * 2013 by Lippincott Williams & Wilkins) LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level III.

BACKGROUND: Hemorrhage following traumatic injury is a leading cause of military and civilian mortality. Noncompressible torso hemorrhage (NCTH) has been identified as particularly lethal, especially in the prehospital setting.METHODS: All patients sustaining NCTH between August 2002 and July 2012 were identified from the UK Joint Theatre Trauma Registry. NCTH was defined as injury to a named torso axial vessel, pulmonary injury, solid-organ injury (Grade 4 or greater injury to the liver, kidney, or spleen) or pelvic fracture with ring disruption. Patients with ongoing hemorrhage were identified using either a systolic blood pressure of less than 90 mm Hg or the need for immediate surgical hemorrhage control. Data on injury pattern and location as well as cause of death were analyzed using univariate and multivariate analyses.RESULTS: During 10 years, 296 patients were identified with NCTH, with a mortality of 85.5%. The majority of deaths occurred before hospital admission (n = 222, 75.0%). Of patients admitted to hospital, survivors (n = 43, 14.5%) had a higher median systolic blood pressure (108 [43] vs. 89 [46], p = 0.123) and Glasgow Coma Scale (GCS) (14 [12] vs. 3 [0], p < 0.001) compared with in-hospital deaths (n = 31, 10.5%). Hemorrhage was the more common cause of death (60.1%), followed by central nervous system disruption (30.8%), total body disruption (5.1%), and multiple-organ failure (4.0%). On multivariate analysis, major arterial and pulmonary hilar injury are most lethal with odds ratio (95% confidence interval) of 16.44 (5.50-49.11) and 9.61 (1.06-87.00), respectively.CONCLUSION: This study demonstrates that the majority of patients sustaining NCTH die before hospital admission, with exsanguination and central nervous system disruption contributing to the bulk cause of death. Major arterial and pulmonary hilar injuries are independent predictors of mortality. (J Trauma Acute Care Surg. 2013; 75: S263YS268. Copyright (C) 2013 by Lippincott Williams & Wilkins)

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a potentially lifesaving maneuver in the setting of hemorrhagic shock. However, emergent use of REBOA is limited by existing technology, which requires large sheath arterial access and fluoroscopy-guided balloon positioning. The objectives of this study were to describe a new, fluoroscopy-free REBOA system and to compare its efficacy to existing technology. An additional objective was to characterize the survivability of 60 minutes of REBOA using these systems in a model of hemorrhagic shock.Swine (70-88 kg) in shock underwent 60 minutes of REBOA using either a self-centering, one component prototype balloon system (PBS, n = 8) inserted (8 Fr) and inflated without fluoroscopy or a two-component, commercially available balloon system (CBS, n = 8) inserted (14 Fr) with fluoroscopic guidance. Following REBOA, resuscitation occurred for 48 hours with blood, crystalloid, and vasopressors. End points included accurate balloon positioning, hemodynamics, markers of ischemia, resuscitation requirements, and mortality.Posthemorrhage mean arterial pressure (mm Hg) was similar in the CBS and PBS groups (35 [8] vs. 34 [5]; p = 0.89). Accurate balloon positioning and inflation occurred in 100% of the CBS and 88% of the PBS group. Following REBOA, mean arterial pressure increased comparably in the CBS and PBS groups (81 [20] vs. 89 [16]; p = 0.21). Lactate peaked in the CBS and PBS groups (10.8 [1.4] mmol/L vs. 13.2 [2.1] mmol/L; p = 0.01) 45 minutes following balloon deflation but returned to baseline by 24 hours. Mortality was similar between the CBS and PBS groups (12% vs. 25%, p = 0.50).This study reports the feasibility and efficacy of a novel, fluoroscopy-free REBOA system in a model of shock. Despite a significant physiologic insult, 60 minutes of REBOA is tolerated and recoverable. Development of lower profile, fluoroscopy-free endovascular balloon occlusion catheters may allow proactive aortic control in patients at risk for hemorrhagic shock and cardiovascular collapse.

Vladimir A. Oppel (1872-1932) was a forefather of military trauma systems. As a surgeon in the Russian Army in World War I, Oppel experienced the challenges and inefficiencies associated with caring for large numbers of combat wounded, the inefficiencies he observed leading to unacceptable morbidity and mortality. As a consequence, Oppel envisioned a coordinated sequence of surgical care on the battlefield and developed the concept of targeted evacuation. In his work, Oppelwas among the first to propose the right operation for the right patient at the right location at the right time. Central to Oppel s precepts were (1) the forward positioning of surgical care close to the point of injury, (2) the development of a reserve of proficient and deployable military surgeons, and (3) the provision of specialized surgery to optimize survival and reduce morbidity. Oppel s teachings were validated during World War II in the performance of the Soviet casualty evacuation system and in all modern wars modern since. Today, nearly 100 years after the work of Vladimir Oppel, the benefits of a coordinated or targeted trauma system, working to optimize survival after trauma, are well recognized around the world.

BACKGROUND: Noncompressible torso hemorrhage (NCTH) is the leading cause of potentially survivable trauma in the battlefield and has recently been defined using anatomic and physiologic criteria. The objective of this study was to characterize the frequency and mortality in combat of NCTH using a contemporary definition. METHODS: Four categories of torso injury, each based on vascular disruption, were identified in US military casualties from the Department of Defense Trauma Registry (2002-2010): (1) thoracic, including lung; (2) solid organ (high-grade spleen, liver, and kidney); (3) named axial vessel; and (4) pelvic fracture with ring disruption. Injuries within these categories were evaluated in the context of physiologic indicator of shock and/or the need for operative hemorrhage control. RESULTS: Of 15,209 battle injuries sustained during the study period, 12.7% (n = 1,936) had sustained one or more categories of torso injury. Of these, 331 (17.1%) had evidence of shock or the need for urgent hemorrhage control, with a mean (SD) Injury Severity Score (ISS) and mortality rate of 30 (13) and 18.7%, respectively. Pulmonary injuries were most numerous (41.7%), followed by solid-organ (29.3%), vascular (25.7%), and pelvic (15.1%) injuries. Following multivariate analysis, the most mortal injury complexes were identified as major arterial injury (odds ratio, 3.38; 95% confidence interval, 1.17-9.74) and pulmonary injury (odds ratio, 2.23; 95% confidence interval, 1.23-4.98). CONCLUSION: NCTH can be defined using anatomic parameters combined with physiologic and operative interventions suggestive of hemorrhage. Major arterial and pulmonary injuries contribute most significantly to the mortality burden. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III. Language: en

Background The evidence for resuscitative thoracotomy (RT) in trauma patients following wartime injury is limited; its indications and timings are less defined in battle injury. The aim of this study was to analyze survival as well as the causes and times of death in patients undergoing RT within the context of modern battlefield resuscitation. Methods A retrospective cohort study was performed on consecutive admissions to a Field Hospital in Southern Afghanistan. All patients undergoing RT were identified using the UK Joint Theatre Trauma Registry. The primary outcome was 30-day mortality, and secondary outcomes included location of cardiac arrest, time from arrest to thoracotomy, and proportion achieving a return of spontaneous circulation. Results Between April 2006 to March 2011, 65 patients underwent RT with 14 survivors (21.5%). Ten patients (15.4%) had an arrest in the field with no survivors, 29 (44.6%) had an arrest en route with 3 survivors, and 26 (40.0%) had an arrest in the emergency department with 11 survivors. There was no difference in Injury Severity Scores (ISSs) between survivors and fatalities (27.3 [7.6] vs. 36.0 [22.1], p = 0.636). Survivors had a significantly shorter time to thoracotomy than did fatalities (6.15 [5.8] minutes vs. 17.7 [12.63] minutes, p Conclusion RT following combat injury will yield survivors. Best outcomes are in patients who have an arrest in the emergency department or on admission to the hospital. Level of evidence Epidemiologic/prognostic study, level III.

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.

BACKGROUND: Critical evaluation of all aspects of combat casualty care, including mortality, with a special focus on the incidence and causes of potentially preventable deaths among US combat fatalities, is central to identifying gaps in knowledge, training, equipment, and execution of battlefield trauma care. The impetus to produce this analysis was to develop a comprehensive perspective of battlefield death, concentrating on deaths that occurred in the preYmedical treatment facility (pre-MTF) environment. METHODS: The Armed Forces Medical Examiner Service Mortality Surveillance Division was used to identify Operation Iraqi Freedom and Operation Enduring Freedom combat casualties from October 2001 to June 2011 who died from injury in the deployed environment. The autopsy records, perimortem records, photographs on file, and Mortality Trauma Registry of the Armed Forces Medical Examiner Service were used to compile mechanism of injury, cause of injury, medical intervention performed, Abbreviated Injury Scale (AIS) score, and Injury Severity Score (ISS) on all lethal injuries. All data were used by the expert panel for the conduct of the potential for injury survivability assessment of this study. RESULTS: For the study interval between October 2001 and June 2011, 4,596 battlefield fatalities were reviewed and analyzed. The stratification of mortality demonstrated that 87.3% of all injury mortality occurred in the pre-MTF environment. Of the pre-MTF deaths, 75.7% (n = 3,040) were classified as nonsurvivable, and 24.3% (n = 976) were deemed potentially survivable (PS). The injury/physiologic focus of PS acute mortality was largely associated with hemorrhage (90.9%). The site of lethal hemorrhage was truncal (67.3%), followed by junctional (19.2%) and peripheral-extremity (13.5%) hemorrhage. CONCLUSION: Most battlefield casualties died of their injuries before ever reaching a surgeon. As most pre-MTF deaths are nonsurvivable, mitigation strategies to impact outcomes in this population need to be directed toward injury prevention. To significantly impact the outcome of combat casualties with PS injury, strategies must be developed to mitigate hemorrhage and optimize airway management or reduce the time interval between the battlefield point of injury and surgical intervention. Understanding battlefield mortality is a vital component of the military trauma system. Emphasis on this analysis should be placed on trauma system optimization, evidence-based improvements in Tactical Combat Casualty Care guidelines, data-driven research, and development to remediate gaps in care and relevant training and equipment enhancements that will increase the survivability of the fighting force. (J Trauma Acute Care Surg. 2012;73: S431YS437. Copyright * 2012 by Lippincott Williams & Wilkins)

Traumatic injuries to the lower gastrointestinal tract occur in up to 15% of all injured combatants, with significant morbidity (up to 75%) and mortality. The incidence, etiology, associated injuries, and overall mortality related to modern battlefield colorectal trauma are poorly characterized.Using data from the Joint Theater Trauma Registry and other Department of Defense electronic health records, the ongoing Joint Surgical Transcolonic Injury or Ostomy Multi-theater Assessment project quantifies epidemiologic trends in colon injury, risk factors for prolonged or perhaps unnecessary fecal diversion, and quality of life in US military personnel requiring colostomies. In the current study, all coalition troops with colon or rectal injuries as classified by DRG International Classification of Diseases-9th Rev. diagnosis and Abbreviated Injury Scale (AIS) codes in the Joint Theater Trauma Registry were included.During 8 years, 977 coalition military personnel with colorectal injury were identified, with a mean (SD) Injury Severity Score (ISS) of 22.2 (13.2). Gunshot wounds remain the primary mechanism of injury (57.6%). Compared with personnel with colon injuries, those with rectal trauma sustained greater injury to face and extremities but fewer severe thoracic and abdominal injuries (p0.005). Overall fecal diversion rates were significantly higher in Iraq than in Afghanistan (38.7% vs. 31.6%, respectively; p = 0.03), predominantly owing to greater use of diversion for colon trauma. There was little difference in diversion rates between theaters for rectal injuries (59.6% vs. 50%, p0.15). The overall mortality rate was 8.2%. Notably, the mortality rate for patients with no fecal diversion (10.8%) was significantly greater than those with fecal diversion (3.7%, p0.0001).Military personnel sustaining colon or rectal trauma continue to have elevated mortality rates, even after reaching surgical treatment facilities. Furthermore, associated serious injuries are commonly encountered. Fecal diversion in these patients may lead to reduced mortality, although prospective selection criteria for diversion do not currently exist. Future research into risk factors for colostomy creation, timing of diversion in relation to damage-control laparotomy, and quality of life in veterans with stomas will produce useful insights and help guide therapy.Epidemiologic study, level III.

OBJECTIVE: Hundreds of general surgeons from the army, navy, and air force have been deployed during the past 10 years to support combat forces, but little data exist on their preparedness to handle the challenging injuries that they are currently encountering. Our objective was to assess operative and operational experience in theater with the goal of improving combat readiness among surgeons. METHODS: A detailed survey was sent to 246 active duty surgeons from the army, navy, and air force who have been deployed at least once in the past 10 years, requesting information on cases performed, perceptions of efficacy of pre-deployment training, knowledge deficits, and post-deployment emotional challenges. Survey data were kept confidential and analyzed using standard statistical methods. RESULTS: Of 246 individuals, 137 (56%) responded and 93 (68%) have been deployed two or more times. More than 18,500 operative procedures were reported, with abdominal and soft tissue cases predominating. Many surgeons identified knowledge or practice gaps in pre-deployment vascular (46%), neurosurgical (29.9%), and orthopedic (28.5%) training. The personal burden of deployment manifested itself with both family (approximately 10% deployment-related divorce rate) and personal (37 surgeons [27%] with two or more symptoms of posttraumatic stress syndrome) stressors. CONCLUSION: These data support modifications of pre-deployment combat surgical training to include increased exposure to open vascular procedures and curriculum traditionally outside general surgery (neurosurgery and orthopedics). The acute care surgical model may be ideal for the military surgeon preparing for deployment. Further research should be directed toward identifying factors contributing to psychological stress among military medics.

BACKGROUND: The died of wounds (DOW) rate is cited as a measure of combat casualty care effectiveness without the context of injury severity or insight into lethality of the battlefield. The objective of this study was to characterize injury severity and other factors related to variations in the DOW rate. METHODS: The highest monthly DOW (HDOW) and lowest monthly DOW (LDOW) rates from 2004 to 2008 were identified from analysis and casualty report databases and used to direct a search of the Joint Theater Trauma Registry. Casualties from the HDOW and LDOW were combined into cohorts, and injury data were analyzed and compared. RESULTS: The HDOW rates were 13.4%, 11.6%, and 12.8% (mean, 12.6%), and the LDOW rates were 1.3%, 2.0%, and 2.7% (mean, 2.0%) ( p 0.0001). The HDOW (n 541) and LDOW (n 349) groups sustained a total of 1,154 wounds. Injury Severity Score was greater in the HDOW than the LDOW group (mean [SD], 11.1 [0.53] vs. 9.4 [0.58]; p 0.03) as was the percentage of patients with Injury Severity Score of more than 25 (HDOW, 12% vs. LDOW, 7.7%; p 0.04). Excluding minor injuries (Abbreviated Injury Scale score of 1), there was a greater percentage of chest injuries in the HDOW compared with the LDOW group (16.5% vs. 11.2%, p 0.03). Explosive mechanisms were more commonly the cause of injury in the HDOW group (58.7% vs. 49.7%; p 0.007), which also had a higher percentage of Marine Corps personnel (p 0.02). CONCLUSION: This study provides novel data demonstrating that the died of wounds rate ranges significantly throughout the course of combat. Discernible differences in injury severity, wounding patterns, and even service affiliation exist within this variation. For accuracy, the died of wounds rate should be cited only in the context of associated injury patterns, injury severity, and mechanisms of injury. Without this context, DOW should not be used as a comparative medical metric.

Battlefield care given to a casualty before hospital arrival impacts clinical outcomes. To date, the published data regarding care given in the prehospital setting of a combat zone are limited. The purpose of this study was to describe the incidence and efficacy of specific prehospital lifesaving interventions (LSIs; interventions that could affect the outcome of the casualty), consistent with the Tactical Combat Casualty Care paradigm, performed during the resuscitation of casualties in a combat zone.We performed a prospective observational study between November 2009 and November 2011. Casualties were enrolled as they were treated at six US surgical facilities in Afghanistan. Descriptive data were collected on a standardized data collection form and included mechanism of injury, airway management, chest and hemorrhage interventions, vascular access, type of fluid administered, and hypothermia prevention. On arrival to the military hospital, the treating physician determined whether an intervention was performed correctly and whether an intervention was not performed that should have been performed (missed LSI).A total of 1,003 patients met the inclusion criteria. Their mean (SD) age was 25 (8.5) years and 97% were male. The mechanism of injury was explosion in 60% of patients, penetrating in 24% of patients, blunt in 15% of patients, and burn in 0.8% of patients. The most commonly performed LSIs included hemorrhage control (n = 599), hypothermia prevention (n = 429), and vascular access (n = 388). Of the missed LSIs, 252 were identified with the highest percentage of missed opportunities being composed of endotracheal intubation, chest needle decompression, and hypotensive resuscitation. In contrast, tourniquet application had the lowest percentage of missed opportunities.In our prospective study of prehospital LSIs performed in a combat zone, we observed a higher rate of incorrectly performed and missed LSIs in airway and chest (breathing) interventions than hemorrhage control interventions. The most commonly performed LSIs had lower incorrect and missed LSI rates.

As part of the 2011 American Association for the Surgery of Trauma (AAST) meeting in Chicago, the Military Liaison Committee led an interactive, case-based debate of vascular trauma and hemorrhage control entitled Tourniquets, Vascular Shunts and Endovascular Technologies: Esoteric or Essential? During the panel session, use of a real-time audience response system resulted in a sensing session during- which opinions and practice patterns related to these topics were tabulated. The purpose of this report is to provide the results from the audience response system gathered during this session as well as select peer-reviewed publications cited during the presentation of each scenario. In addition, the objective of this summary is to provide a perspective as to whether these surgical adjuncts or techniques are esoteric or essential in contemporary trauma practice.