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Introduction: Damage control laparotomy (DCL) in an austere environment is an evolving surgical modality., Methods: A retrospective evaluation of all patients surviving 24 hours who underwent a laparotomy from 2002 to 2011 in Iraq and Afghanistan was performed. DCL was defined as a patient undergoing laparotomy at two distinct North American Treaty Organization (NATO) Role 2 or 3 medical treatment facilities (MTFs); a NATO Roles 2 and 3 MTFs, and/or having the International Classification of Diseases, 9th Revision, Clinical Modification procedure code 54.12, for reopening of recent laparotomy site. Definitive laparotomy (DL) was defined as patients undergoing one operative procedure at one NATO Role 2 or 3 MTF. Demographic data including injury severity scores, hematological transfusion, mortality, intraperitoneal or retroperitoneal operative interventions, and complications were compared., Results: DCL composed of 26.5% (n = 331) of all 1,248 laparotomies performed between March 2002 and September 2011. Total intra-abdominal, acute respiratory distress syndrome, and thromboembolic complications for DCL versus DL were 8.5% and 5.6% (p = 0.07), 2.1% and 0.8% (p = 0.06), and 1.5% and 0.7% (p = 0.17), respectively. Theater discharge mortality from DCL and DL were 1.5% (n = 5), and 1.4% (n = 13) (p = 0.90), respectively., Conclusions: In conclusion, excluding deaths with the first 24 hours, DCL and DL had comparable mortality and complication rates at NATO Roles 2 and 3 MTFs., (Reprint & Copyright © 2016 Association of Military Surgeons of the U.S.)

Introduction: On January 11th 2013, France launched Operation Serval in Mali following Resolution 2085 of the Security Council of the United Nations. Between January and March 2013, more than 4000 French soldiers were deployed to support the Malian National Army and the African Armed Forces., Methods: All of the patients who had surgery during Operation Serval were entered into a computerised database. Patients' demographic data (age, sex, status) and types of performed surgical procedures (specialties, injury mechanisms) were recorded., Results: 268 patients were operated on in Gao's Role 2 with a total of 296 surgeries. Among those operated on, 40% were Malian civilians, 24% were French soldiers, and 36% were soldiers of the International Coalition Forces. The majority of the surgeries were orthopaedic, and visceral surgeries were common as well, representing 43% of the total surgeries. Specialised surgical procedures including neurosurgery, thoracic, and vascular surgery were also performed. Forty percent of the surgeries were scheduled. War-related traumatic surgeries represented 22% of the surgical procedures, with non-war related surgeries and non-trauma emergency surgeries making up the rest., Conclusion: this analysis confirms the specific characteristic of asymmetric warfare that it results in a relatively reduced number of war-related casualties. Forward surgical teams have to deal with a wide range of injuries requiring several surgical specialties. Surgeries dedicated to medical aid provided to the population also represented an important part of the surgical activity. Because of the diversity and the technicality of the surgical procedures in Role 2, surgeons had to be trained in war surgery covering all of the surgical specialties, while they maintained their specific skills. In France in 2007, the French Military Health Service Academy (École du Val-de-Grâce, Paris, France) offered an advanced course in surgery for deployment in combat zones, with a special focus on damage control surgeries and the management of mass casualties incidents., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Aims: To identify the prevalence, injury patterns and mortality of penetrating abdominal injury in patients treated at the UK Role 3 Medical Treatment Facility (MTF) in Camp Bastion, Afghanistan., Methods: All patients with a penetrating abdominal injury were identified from the UK Joint Theatre Trauma Registry (JTTR). Demographics, predicted survival and observed mortality were compared. Sub-group analyses of UK military patients were conducted, comparing changes in survival as the campaign progressed and identifying the anatomical distribution of abdominal injuries., Results: Between June 2006 and June 2013, 1331 of the 8558 (16%) patients recorded on the JTTR had a penetrating abdominal injury; 393 were UK military, of whom 175 (45%) survived. 71% of UK military fatalities had the maximum New Injury Severity Score (NISS) of 75 compared to 4.6% of UK military survivors. The survival rate of UK military patients increased in the later stages of the campaign. Fatal injury in UK military patients was associated with significant vascular or hepatic injuries., Conclusions: This study has defined the epidemiology of penetrating abdominal injury in a modern conflict. Continued training and further research into injury prevention and management will help to ensure that the improved outcomes observed in Afghanistan continue on future operations.

Introduction: In the civilian trauma literature, femoral neck fractures in young adults are considered an orthopedic 'urgency'. To our knowledge, there have been no studies looking at the outcomes of these injuries in the combat setting. The purpose of this study is to determine the outcomes of war related femoral neck fractures; the rates avascular necrosis associated with these injuries as well as the effect time to fixation has on the development of avascular necrosis., Methods: We performed a retrospective review of 21 patients who sustained combat related femoral neck fractures from October 2001 through October 2013. We collected demographic data, time to fixation, time to union, incidence of avascular necrosis, as well as complications and final recreational activity status., Results: Our study included 21 males (100%). The average length of follow up was 19.0 (2.7-62.3) months, and the average length of radiographic follow up was 21.4 months. The average age was 25.2 (21-36) years. Displaced fractures were sustained in 71.4% of patients and 95.2% had a Pauwels' type 3 fracture. 56.9% had initial reduction and fixation within 24h of injury. Percutaneous screw fixation and dynamic hip screws were definitive fixation in 57.1% and 23.8% of patients, respectively, while the remainder had a cephalomedullary device or a salvage procedure. The average time to union was 5.5 months. There was 1 case of nonunion and 1 case of delayed union. Three of the patients (16.7%) developed avascular necrosis of the femoral head, 2 of which were initially reduced within 24h of injury. There were no statistically significant differences between time to fixation, type of reduction, or presence of displacement as a predictor of the development of avascular necrosis., Discussion: We found a high rate of displaced and high Pauwels' angle fractures, consistent with the high-energy injury mechanisms. With nearly a two-year average radiographic follow-up, the incidence of avascular necrosis was 16.7%, despite only half of our patients receiving initial reduction within 24h of injury. Urgent reduction and fixation continues to be of utmost importance to decrease the risk of femoral head avascular necrosis., (Published by Elsevier Ltd.)

Background: In Afghanistan, care of the acutely injured trauma patient commonly occurred in facilities with limited blood banking capabilities. Apheresis platelets were often not available. Component therapy consisted of 1:1 packed red blood cells and fresh frozen plasma. Fresh, whole blood transfusion often augmented therapy in the severely injured patient. This study analyzed the safety of fresh, whole blood use in a resource-limited setting., Methods: A retrospective analysis was performed on a prospectively collected data set of US battle injuries presenting to three US Marine Corps (USMC) expeditionary surgical care facilities in Helmand Province, Afghanistan, between January 2010 and July 2012. Included in the review were patients with Injury Severity Scores (ISSs) of 15 or higher receiving blood transfusions. Univariate analyses were performed, followed by multivariable logistic regression to describe the relationship between the treatment group and posttreatment complications such as trauma-induced coagulopathy, infection, mortality, venous thromboembolism, and transfusion reaction. Propensity scores were calculated and included in multivariable models to adjust for potential bias in treatment selection., Results: A total of 61 patients were identified; all were male marines with a mean (SD) age of 23.5 (3.6) years. The group receiving fresh, whole blood was noted to have higher ISSs and lower blood pressure, pH, and base deficits on arrival. Traumatic coagulopathy was significantly less common in the group receiving fresh, whole blood (odds ratio, 0.01; 95% confidence interval, 0.00-0.18). Multivariable models found no other significant differences between the treatment groups., Conclusion: The early use of fresh, whole blood in a resource-limited setting seems to confer a benefit in reducing traumatic coagulopathy. This study's small sample size precludes further statement on the overall safety of fresh, whole blood use., Level of Evidence: Therapy study, level IV.

Introduction: In recent military conflicts, military surgeons encounter more high-energy injuries associated with explosives. Advances in the field care and shorter evacuation time increased survival. However, casualties still incur severe injuries especially to the extremities. We present wound patterns, anatomical distribution and severity of injuries in a Role 2 hospital., Materials and Methods: Two years data have been retrospectively reviewed. Only explosives and firearms injuries were included in the study. Patient profile, admission details, mechanism of injury, AIS anatomical locations, ISS, surgical and medical treatments have been analyzed., Results: Data revealed 170 male casualties. IEDs and GSW accounted for 133 (78%) and 37 (22%) casualties, respectively. An average of 1.8 IED and 1.2 GSW anatomical locations were exposed to injuries. Regardless of the mechanism, injuries were most commonly located in the extremities. IEDs caused significantly higher soft tissue injuries., Discussion: Explosives do not necessarily cause more severe injuries than firearms. However, fragments create multiple, complicated soft tissue injuries which constitute more than half of the injuries. Timely wound debridement and excision of contaminated tissue are crucial to manage extremity soft tissue injuries., Conclusion: Casualty care should be assessed within the context of the capabilities present at a hospital and the cause, type and severity of the wounds. The NATO description of Role 2 care only requires an integrated surgical team for damage control surgery with limited diagnostic and infrastructural capabilities.

Background: In the presence an armed conflagration, the mortality behavior of a country is expected to be affected. The aim of this investigation was to assess, in a country with internal warfare, the trend of mortality associated with traumatic brain injury in children and adolescents, which even under social peace conditions, is one of the most common causes of death and disability in this population groups., Methods: A retrospective, population-based study was conducted, where the trend of mortality due to traumatic brain injury during the 1999 to 2008 period was assessed. A linear regression was performed to establish its correlation with mortality associated with warfare events of the armed conflict., Results: Global mortality rate was 12.7 per 100 000 inhabitants. The temporary analysis showed a -9.67% annual decrease throughout the entire period of study (95 % CI = -9.25 % to -10.1 %; p < 0.001). The mortality rate was increased by 0.28 and 0.62 for each incremental unit in the armed conflict-related violent death rate and in civilian population, respectively., Conclusions: In an armed conflict scenario, mortality behavior varies according to the intensity of warfare actions. Mortality due to traumatic brain injury in children and adolescents can be used as an indicator of the impact of war on civilian population not involved with the armed conflict.