A trauma expert consensus: Capabilities are required early to improve survivability from traumatic injury.

BACKGROUND: Mortality reviews examine US military fatalities resulting from traumatic injuries during combat operations. These reviews are essential to the evolution of the military trauma system to improve individual, unit, and system-level trauma care delivery and inform trauma system protocols and guidelines. This study identifies specific prehospital and hospital interventions with the potential to provide survival benefits. METHODS: US Special Operations Command fatalities with battle injuries deemed potentially survivable (2001-2021) were extracted from previous mortality reviews. A military trauma review panel consisting of trauma surgeons, forensic pathologists, and prehospital and emergency medicine specialists conducted a methodical review to identify prehospital, hospital, and resuscitation interventions (e.g., laparotomy, blood transfusion) with the potential to have provided a survival benefit. RESULTS: Of 388 US Special Operations Command battle-injured fatalities, 100 were deemed potentially survivable. Of these (median age, 29 years; all male), 76.0% were injured in Afghanistan, and 75% died prehospital. Gunshot wounds were in 62.0%, followed by blast injury (37%), and blunt force injury (1.0%). Most had a Maximum Abbreviated Injury Scale severity classified as 4 (severe) (55.0%) and 5 (critical) (41.0%). The panel recommended 433 interventions (prehospital, 188; hospital, 315). The most recommended prehospital intervention was blood transfusion (95%), followed by finger/tube thoracostomy (47%). The most common hospital recommendations were thoracotomy and definitive vascular repair. Whole blood transfusion was assessed for each fatality: 74% would have required ≥10 U of blood, 20% would have required 5 to 10 U, 1% would have required 1 to 4 U, and 5% would not have required blood products to impact survival. Five may have benefited from a prehospital laparotomy. CONCLUSION: This study systematically identified capabilities needed to provide a survival benefit and examined interventions needed to inform trauma system efforts along the continuum of care. The determination was that blood transfusion and massive transfusion shortly after traumatic injury would impact survival the most. LEVEL OF EVIDENCE: Expert Opinion; Level V.

Catastrophic CPR-Related Injuries in Vascular Ehlers-Danlos Syndrome: A Case Report and Review.

ABSTRACT: This article presents a case of severe CPR-related injuries leading to diagnosis of vascular Ehlers-Danlos syndrome. The subject is a 36-year-old female with a past medical history of a 10-mm aneurysm of the right internal carotid artery discovered on imaging 3 years prior to death. Major autopsy findings included subarachnoid hemorrhage in the base of the brain, bilateral hemothoraces, hemopericardium, laceration of the interatrial septum, laceration of the left pulmonary artery, and changes secondary to chronic alveolar hemorrhage in the lungs. The autopsy findings and subsequent unremarkable toxicology studies led to the suspicion of an underlying and clinically undiagnosed connective tissue disorder. Broad genetic exome testing revealed a mutation consistent with vascular Ehlers-Danlos syndrome. An overview of this disease, its diagnosis, and differential are further described herein, along with recommendations for forensic pathologists.

A Review of 75th Ranger Regiment Battle-Injured Fatalities Incurred During Combat Operations From 2001 to 2021.

INTRODUCTION: The 75th Ranger Regiment is an elite U.S. military special operations unit that conducted over 20 years of sustained combat operations. The Regiment has a history of providing novel and cutting-edge prehospital trauma care, advancing and translating medical initiatives, and documenting and reporting casualty care performance improvement efforts. MATERIALS AND METHODS: A retrospective case fatality rate (CFR) review, mortality review, and descriptive analysis of fatalities were conducted for battle-injured personnel assigned or attached to the 75th Ranger Regiment from 2001 to 2021 during combat operations primarily in Afghanistan and Iraq. Fatalities were evaluated for population characteristics, cause of death, mechanism of death, injury severity, injury survivability, and death preventability. RESULTS: A total of 813 battle injury casualties, including 62 fatalities, were incurred over 20 years and 1 month of continuous combat operations. The Regiment maintained a zero rate of prehospital preventable combat death. Additionally, no fatalities had a mechanism of death because of isolated extremity hemorrhage, tension pneumothorax, or airway obstruction. When comparing the CFR of the Regiment to the U.S. military population as a whole, the Regiment had a significantly greater reduction in the cumulative CFR as measured by the difference in average annual percentage change. CONCLUSIONS: Documentation and analysis of casualties and care, mortality and casualty reviews, and other performance improvement efforts can guide combatant commanders, medical directors, and fighting forces to reduce preventable combat deaths and the CFR. Early hemorrhage control, blood product resuscitation, and other lifesaving interventions should be established and maintained as a standard prehospital practice to mitigate fatalities with potentially survivable injuries.

Finding the bleeding edge: 24-hour mortality by unit of blood product transfused in combat casualties from 2002-2020.

BACKGROUND: Transfusion studies in civilian trauma patients have tried to identify a general futility threshold. We hypothesized that in combat settings there is no general threshold where blood product transfusion becomes unbeneficial to survival in hemorrhaging patients. We sought to assess the relationship between the number of units of blood products transfused and 24-hour mortality in combat casualties. METHODS: A retrospective analysis of the Department of Defense Trauma Registry supplemented with data from the Armed Forces Medical Examiner. Combat casualties who received at least one unit of blood product at US military medical treatment facilities (MTFs) in combat settings (2002-2020) were included. The main intervention was the total units of any blood product transfused, which was measured from the point of injury until 24 hours after admission from the first deployed MTF. The primary outcome was discharge status (alive, dead) at 24 hours from time of injury. RESULTS: Of 11,746 patients included, the median age was 24 years, and most patients were male (94.2%) with penetrating injury (84.7%). The median injury severity score was 17 and 783 (6.7%) patients died by 24 hours. Median units of blood products transfused was 8. Most blood products transfused were red blood cells (50.2%), followed by plasma (41.1%), platelets (5.5%), and whole blood (3.2%). Among the 10 patients who received the most units of blood product (164 units to 290 units), 7 survived to 24 hours. The maximum amount of total blood products transfused to a patient who survived was 276 units. Of the 58 patients who received over 100 units of blood product, 20.7% died by 24 hours. CONCLUSION: While civilian trauma studies suggest the possibility of futility with ultra-massive transfusion, we report that the majority (79.3%) of combat casualties who received transfusions greater than 100 units survived to 24 hours. These results do not support a threshold for futility of blood product transfusion. Further analysis as to predictors for mortality will help in situations of blood product and resource constraints. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

United States Military Fatalities During Operation Inherent Resolve and Operation Freedom's Sentinel.

BACKGROUND: Military operations provide a unified action and strategic approach to achieve national goals and objectives. Mortality reviews from military operations can guide injury prevention and casualty care efforts. METHODS: A retrospective study was conducted on all U.S. military fatalities from Operation Inherent Resolve (OIR) in Iraq (2014-2021) and Operation Freedom's Sentinel (OFS) in Afghanistan (2015-2021). Data were obtained from autopsy reports and other existing records. Fatalities were evaluated for population characteristics; manner, cause, and location of death; and underlying atherosclerosis. Non-suicide trauma fatalities were also evaluated for injury severity, mechanism of death, injury survivability, death preventability, and opportunities for improvement. RESULTS: Of 213 U.S. military fatalities (median age, 29 years; male, 93.0%; prehospital, 89.2%), 49.8% were from OIR, and 50.2% were from OFS. More OIR fatalities were Reserve and National Guard forces (OIR 22.6%; OFS 5.6%), conventional forces (OIR 82.1%; OFS 65.4%), and support personnel (OIR 61.3%; OFS 33.6%). More OIR fatalities also resulted from disease and non-battle injury (OIR 83.0%; OFS 28.0%). The leading cause of death was injury (OIR 81.1%; OFS 98.1%). Manner of death differed as more homicides (OIR 18.9%; OFS 72.9%) were seen in OFS, and more deaths from natural causes (OIR 18.9%; OFS 1.9%) and suicides (OIR 29.2%; OFS 6.5%) were seen in OIR. The prevalence of underlying atherosclerosis was 14.2% in OIR and 18.7% in OFS. Of 146 non-suicide trauma fatalities, most multiple/blunt force injury deaths (62.2%) occurred in OIR, and most blast injury deaths (77.8%) and gunshot wound deaths (76.6%) occurred in OFS. The leading mechanism of death was catastrophic tissue destruction (80.8%). Most fatalities had non-survivable injuries (80.8%) and non-preventable deaths (97.3%). CONCLUSIONS: Comprehensive mortality reviews should routinely be conducted for all military operation deaths. Understanding death from both injury and disease can guide preemptive and responsive efforts to reduce death among military forces.

Determining resuscitation outcomes in combat casualties: Design of the Deployed Hemostatic Emergency Resuscitation of Traumatic Exsanguinating Shock (Deployed HEROES) study.

BACKGROUND: During the course of the recent conflicts, the recommendations for resuscitation practices have evolved, but there has been no comprehensive comparative effectiveness study of these resuscitation strategies. The objective of this study was to describe the development and study design of the Deployed Hemostatic Emergency Resuscitation of Traumatic Exsanguinating Shock (Deployed HEROES) study-the first comprehensive analysis of military resuscitation practices in the deployed environment from October 2001 to October 2019. METHODS: This retrospective cohort study uses the Department of Defense Trauma Registry, Armed Services Blood Program database, and Military Trauma Mortality Review, while abstractors will use Theater Medical Data Store and Web Interface Patient Records to collect transfusion timing data. This study includes patients, who received blood products or died before receiving blood, treated at US military medical treatment facilities. The primary endpoints are survival at 6 hours, 24 hours, and 30 days postinjury. Secondary outcomes include infection, renal dysfunction, pulmonary dysfunction, and thromboembolic event. Exposure will be defined by blood product transfusion. Study groups will be frequency matched. Cox proportional hazards will compare patients who received warm fresh whole blood, low titer type-O whole blood, or only component therapy, while using adjustment for type of blood product transfused as a time-dependent covariate. Multilevel mixed-effects logistic regression will determine the effect of incompatible plasma in low titer type-O whole blood. RESULTS: An analysis plan for the Deployed HEROES study was developed with the aim of minimizing bias. CONCLUSION: This study will inform the optimal resuscitation strategies, which will potentially have a substantial impact on combat mortality. If whole blood is found to be the optimal transfusion strategy, this finding will be crucial in future operating environments involving dispersed medical assets. These results will provide critical information necessary for combat casualty care guidelines. LEVEL OF EVIDENCE: Prognostic and epidemiological; Level III.

Low-grade endometrial stromal sarcoma with extensive sex cord differentiation, heterologous elements, and complex atypical hyperplasia: Case report and review of literature.

•Endometrial stromal sarcoma (ESS) may have sex cord differentiation, usually focal.•Diagnosis of ESS is difficult when variant morphology predominates.•Prognosis differs between ESS and UTROSCT; therefore, distinction is critical.•Extensive tumor sampling is mandatory to identify neoplastic endometrial stroma.•Sex cord differentiation may be associated with endometrial hyperplasia.

A real-time fluorescence polymerase chain reaction assay for the identification of Yersinia pestis using a field-deployable thermocycler.

Real-time fluorescence polymerase chain reaction is a microbial identification method that can provide rapid and accurate results using a field-deployable thermocycler, the RAPID ("ruggedized" advanced pathogen identification device). A Yersinia pestis-specific TaqMan assay required approximately 75 minutes and achieved a sensitivity of 100 fg of Y. pestis genomic DNA (20 genome equivalents). Specificity testing against a genomic DNA cross-reaction panel comprised of 22 bacterial species encountered in the respiratory tract resulted in no false positives. No cross-reaction occurred with human genomic DNA.