Missed injuries in combat casualties: Lessons from Iraq and Afghanistan.

INTRODUCTION: Once injured in the battlefield in Iraq and Afghanistan, U.S. and NATO troops receive medical treatment through tiered echelons of care with varying resources, from austere to state-of-the-art. Similar to civilian trauma systems, the aim is to provide rapid and safe patient movement toward definitive management. A consequence of the rapid transfer of patients is the possibility of missed or delayed diagnosis of injuries. With the new injury patterns seen during these conflicts, we aimed to identify and characterize which injuries are missed and what consequences do they have on our troops' road to recovery. PATIENTS AND METHODS: A retrospective review of a PI database (established 2007) for consecutively admitted combat casualties was performed between 2007-2013. Baseline patient characteristics, injury year, admitting service, injury type, and subsequent management decisions were categorized and analyzed. RESULTS: There were 301 missed injuries (MI) identified in 248 patients. The annual missed injury rate was 25 per 1000 admissions. Missed injuries were associated with a penetrating mechanism (82.7% vs 58.5%, p < 0.001), ICU admission (58.5% vs 27.4%, p < 0.001), higher ISS (median 14 vs 8, p < 0.001), and a longer length of stay (median 3 versus 2 days, p < 0.001). 194 (64.5%) missed injuries led to a change in management, with 68 (22.6%) requiring a surgical procedure. 1.3% of missed injuries were life threatening, 28.2% major and 65.4% minor. The most common injuries were distal extremity fractures (23.9%), followed by spine fractures (13.3%) and traumatic tympanic membrane rupture (12.6%), There were no deaths attributed to a missed injury. DISCUSSION: Missed injuries during combat operations occur on a low but consistent basis. Most injuries are orthopedic in nature and typically occur in critically ill patients admitted to the ICU. It is rare that a missed injury results in a life-threatening condition. CONCLUSION: As healthcare practitioners prepare for future deployments, this analysis may serve as a resource to focus on frequently missed injuries and possibly improve their detection.

Mortality after emergent trauma laparotomy: A multicenter, retrospective study.

BACKGROUND: Two decades ago, hypotensive trauma patients requiring emergent laparotomy had a 40% mortality. In the interim, multiple interventions to decrease hemorrhage-related mortality have been implemented but few have any documented evidence of change in outcomes for patients requiring emergent laparotomy. The purpose of this study was to determine current mortality rates for patients undergoing emergent trauma laparotomy. METHODS: A retrospective cohort of all adult, emergent trauma laparotomies performed in 2012 to 2013 at 12 Level I trauma centers was reviewed. Emergent trauma laparotomy was defined as emergency department (ED) admission to surgical start time in 90 minutes or less. Hypotension was defined as arrival ED systolic blood pressure (SBP) ≤90 mm Hg. Cause and time to death was also determined. Continuous data are presented as median (interquartile range [IQR]). RESULTS: One thousand seven hundred six patients underwent emergent trauma laparotomy. The cohort was predominately young (31 years; IQR, 24-45), male (84%), sustained blunt trauma (67%), and with moderate injuries (Injury Severity Score, 19; IQR, 10-33). The time in ED was 24 minutes (IQR, 14-39) and time from ED admission to surgical start was 42 minutes (IQR, 30-61). The most common procedures were enterectomy (23%), hepatorrhaphy (20%), enterorrhaphy (16%), and splenectomy (16%). Damage control laparotomy was used in 38% of all patients and 62% of hypotensive patients. The Injury Severity Score for the entire cohort was 19 (IQR, 10-33) and 29 (IQR, 18-41) for the hypotensive group. Mortality for the entire cohort was 21% with 60% of deaths due to hemorrhage. Mortality in the hypotensive group was 46%, with 65% of deaths due to hemorrhage. CONCLUSION: Overall mortality rate of a trauma laparotomy is substantial (21%) with hemorrhage accounting for 60% of the deaths. The mortality rate for hypotensive patients (46%) appears unchanged over the last two decades and is even more concerning, with almost half of patients presenting with an SBP of 90 mm Hg or less dying.

Damage-control resuscitation and emergency laparotomy: Findings from the PROPPR study.

BACKGROUND: The Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial has demonstrated that damage-control resuscitation, a massive transfusion strategy targeting a balanced delivery of plasma-platelet-red blood cell in a ratio of 1:1:1, results in improved survival at 3 hours and a reduction in deaths caused by exsanguination in the first 24 hours compared with a 1:1:2 ratio. In light of these findings, we hypothesized that patients receiving 1:1:1 ratio would have improved survival after emergency laparotomy. METHODS: Severely injured patients predicted to receive a massive transfusion admitted to 12 Level I North American trauma centers were randomized to 1:1:1 versus 1:1:2 as described in the PROPPR trial. From these patients, the subset that underwent an emergency laparotomy, defined previously in the literature as laparotomy within 90 minutes of arrival, were identified. We compared rates and timing of emergency laparotomy as well as postsurgical survival at 24 hours and 30 days. RESULTS: Of the 680 enrolled patients, 613 underwent a surgical procedure, 397 underwent a laparotomy, and 346 underwent an emergency laparotomy. The percentages of patients undergoing emergency laparotomy were 51.5% (174 of 338) and 50.3% (172 of 342) for 1:1:1 and 1:1:2, respectively (p = 0.20). Median time to laparotomy was 28 minutes in both treatment groups. Among patients undergoing an emergency laparotomy, the proportions of patients surviving to 24 hours and 30 days were similar between treatment arms; 24-hour survival was 86.8% (151 of 174) for 1:1:1 and 83.1% (143 of 172) for 1:1:2 (p = 0.29), and 30-day survival was 79.3% (138 of 174) for 1:1:1 and 75.0% (129 of 172) for 1:1:2 (p = 0.30). CONCLUSION: We found no evidence that resuscitation strategy affects whether a patient requires an emergency laparotomy, time to laparotomy, or subsequent survival. LEVEL OF EVIDENCE: Therapeutic study, level IV.