Prehospital blood transfusion in the en route management of severe combat trauma: a matched cohort study.

BACKGROUND: The value of prehospital blood transfusion (PHBTx) in the management of severe trauma has not been established. This study aimed to evaluate the effect of PHBTx on mortality in combat casualties. METHODS: This is a retrospective cohort study of casualties admitted to the field hospital at Camp Bastion, Afghanistan, by the Medical Emergency Response Team from May 2006 to March 2011. Participants were divided into two consecutive cohorts by the introduction of PHBTx. Paired groups of patients were chosen by combining propensity score methodology with detailed matching of injury profile. Thus recipients of PHBTx were matched with nonrecipients who would have received it had it been available. RESULTS: A total of 1,592 patients were identified. Of the 1,153 patients to whom PHBTx was potentially available, 310 received it (26.9%). The rate of severe injury (Injury Severity Score [ISS] > 15) rose from 28% before PHBTx was available to 43% thereafter (p < 0.001). Mortality in the latter group was higher (14% vs. 10%, p = 0.013) but not in the severely injured patients (32% vs. 28%, p = 0.343). Ninety-seven patients were paired. The mortality of matched patients who received PHBTx, compared with those with similar injury patterns who did not, was less than half (8.2% vs. 19.6%, p < 0.001). However, matched recipients had more prehospital interventions, reached hospital more quickly, and had lower heart rate at admission (all p < 0.05). Matched recipients received more red blood cells within 24 hours (median, 4 U; interquartile range [IQR], 2-10 U) than nonrecipients (median 0 U; IQR, 0-3.5 U) and more fresh frozen plasma (median, 2 U; IQR, 2-9 U vs. median, 0 U; IQR, 0-1 U) (both p < 0.001). CONCLUSION: An aggressive approach to damage control resuscitation including the use of PHBTx was associated with a large improvement in mortality. However, because of confounders resulting from changes in practice, the isolated contribution of PHBTx cannot be determined from this study. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Demographic and geographical characteristics of pediatric trauma in Scotland.

BACKGROUND: Trauma systems reduce mortality and improve functional outcomes. The aim of this study was to analyse the demographic and geospatial characteristics of pediatric trauma patients in Scotland, and determine the level of destination healthcare facility which injured children are taken to, to determine the need for, and general feasibility, of developing a pediatric trauma system for Scotland. METHODS: Retrospective analysis of incidents involving children aged 1-14 attended to by the Scottish Ambulance Service between 1 November 2008 and 31 October 2010. A subgroup with physiological derangement was defined. Incident location postcode was used to determine incident location by health board region, rurality and social deprivation. Destination healthcare facility was classified into one of six categories. RESULTS: Of 10,759 incidents, 72.3% occurred in urban areas and 5.8% in remote areas. Incident location was associated with socioeconomic deprivation. Of the patients, 11.6% were taken to a pediatric hospital with pediatric intensive care facilities, 21.8% to a pediatric hospital without pediatric intensive care service, and 50.2% to an adult large general hospital without pediatric surgical service. CONCLUSIONS: The majority of incidents involving children with injuries occurred in urban areas. Half were taken to a hospital without pediatric surgical service. There was no difference between children with normal and deranged physiology.

Improvements in the hemodynamic stability of combat casualties during en route care.

Three Forward Aeromedical Evacuation platforms operate in Southern Afghanistan: UK Medical Emergency Response Team (MERT), US Air Force Expeditionary Rescue Squadron (PEDRO), and US Army Medical Evacuation Squadrons (DUSTOFF), each with a different clinical capability. Recent evidence suggests that retrieval by a platform with a greater clinical capability (MERT) is associated with improved mortality in critical patients when compared with platforms with less clinical capability (PEDRO and DUSTOFF). It is unclear whether this is due to en route resuscitation or the dispatch procedure. The aim of this study was to compare prehospital Shock Index (SI = heart rate / systolic blood pressure) with admission values as a measure of resuscitation, across these platforms. Patients were identified from the Department of Defense Trauma Registry, who were evacuated between June 2009 and June 2011 in Southern Afghanistan. Data on platform type, physiology, and injury severity was extracted. Overall, 865 patients were identified: 478 MERT, 291 PEDRO, and 96 DUSTOFF patients and groups were compared across three injury severity scoring (ISS) bins: 1 to 9, 10 to 25, and 26 or greater. An improvement in the admission SI was observed across all platforms in the lowest ISS bin. Within the middle bin, both the MERT and PEDRO groups saw improved SI on admission, but not the DUSTOFF group. This trend was continued only in the MERT group for the highest ISS bin (1.39 ± 0.62 vs. 1.09 ± 0.42; P = 0.001), whereas a deterioration was identified in the PEDRO group (0.88 ± 0.37 vs. 1.02 ± 0.43; P = 0.440). The use of a Forward Aeromedical Evacuation platform with a greater clinical capability is associated with an improved hemodynamic status in critical casualties. The ideal prehospital triage should endeavor to match patient need with clinical capability.

Destination healthcare facility of shocked trauma patients in Scotland: analysis of transfusion and surgical capability of receiving hospitals.

AIMS: Haemorrhage is a leading cause of death from trauma. Management requires a combination of haemorrhage control and resuscitation which may incur significant surgical and transfusion utilisation. The aim of this study is to evaluate the resource provision of the destination hospital of Scottish trauma patients exhibiting evidence of pre-hospital shock. METHODS: Patients who sustained a traumatic injury between November 2008 and October 2010 were retrospectively identified from the Scottish Ambulance Service electronic patients record system. Patients with a systolic blood pressure less than 110 mmHg or if missing, a heart rate greater than 120 bpm, were considered in shock. The level of the destination healthcare facility was classified in terms of surgical and transfusion capability. Patients with and without shock were compared. RESULTS: There were 135,004 patients identified, 133,651 (99.0%) of whom had sustained blunt trauma, 68,411 (50.7%) were male and the median (IQR) age was 59 (46). There were 6721 (5.0%) patients with shock, with a similar age and gender distribution to non-shocked patients. Only 1332 (19.8%) of shocked patients were taken to facilities with full surgical capability, 5137 (76.4%) to hospitals with limited (general and orthopaedic surgery only) and 252 (3.7%) to hospitals with no surgical services. In terms of transfusion capability, 5556 (82.7%) shocked patients were admitted to facilities with full capability and 1165 (17.3%) to a hospital with minimal or no capability. CONCLUSIONS: The majority of Scottish trauma patients are transported to a hospital with full transfusion capability, although the majority lack surgical sub-specialty representation.

Interpreting comparative died of wounds rates as a quality benchmark of combat casualty care.

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.

Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003-2004 versus 2006.

BACKGROUND: The opinion that injuries sustained in Iraq and Afghanistan have increased in severity is widely held by clinicians who have deployed multiple times. To continuously improve combat casualty care, the Department of Defense has enacted numerous evidence-based policies and clinical practice guidelines. We hypothesized that the severity of wounds has increased over time. Furthermore, we examined cause of death looking for opportunities of improvement for research and training. METHODS: Autopsies of the earliest combat deaths from Iraq and Afghanistan and the latest deaths of 2006 were analyzed to assess changes in injury severity and causes of death. Fatalities were classified as nonsurvivable (NS) or potentially survivable (PS). PS deaths were then reviewed in depth to analyze mechanism and cause. RESULTS: There were 486 cases from March 2003 to April 2004 (group 1) and 496 from June 2006 to December 2006 (group 2) that met inclusion criteria. Of the PS fatalities (group 1: 93 and group 2: 139), the injury severity score was lower in the first group (27 +/- 14 vs. 37 +/- 16, p < 0.001), and had a lower number of abbreviated injury scores >or=4 (1.1 +/- 0.79 vs. 1.5 +/- 0.83 per person, p < 0.001). The main cause of death in the PS fatalities was truncal hemorrhage (51% vs. 49%, p = NS). Deaths per month between groups doubled (35 vs. 71), whereas the case fatality rates between the two time periods were equivalent (11.0 vs. 9.8, p = NS). DISCUSSION: In the time periods of the war studied, deaths per month has doubled, with increases in both injury severity and number of wounds per casualty. Truncal hemorrhage is the leading cause of potentially survivable deaths. Arguably, the success of the medical improvements during this war has served to maintain the lowest case fatality rate on record.