Transcript Slide 1

Battlefield Trauma :
Lessons from Afghanistan
Jim Holliman, M.D., F.A.C.E.P.
Program Manager
Afghanistan Health Care Sector Reconstruction Project
Center for Disaster and Humanitarian Assistance Medicine
(CDHAM)
Professor of Military and Emergency Medicine
Uniformed Services University of the Health Sciences (USUHS)
Bethesda, Maryland, U.S.A.
Sept. 2009
Battlefield Trauma : Lecture Goals
• Present changes in “epidemiology” of
combat injuries in major current military
conflicts
• Present lessons learned from care of
trauma victims in Afghanistan (and Iraq)
• Point out how some of these lessons are
relevant to civilian medical practice
Lecture Acknowledgement
• Many thanks to Dr. Joe Lex for many of
the slides I stole from him for this lecture
How People Die in
Ground Combat
KIA : CNS injury
KIA : Airway obstruction
KIA : Blast / mutilating
trauma
25%
10%
9%
5%
KIA : Torso trauma, not
correctable
7%
1%
KIA : Tension PTX
12%
31%
(KIA = Killed in
Action ; DOW =
Died of Wounds)
KIA : Torso trauma,
correctable
KIA : Extremity
exsanguination
DOW : Infection, shock
complications
How People Die in
Ground Combat
KIA: CNS injury
KIA: Airway obstruction
KIA: Blast / mutilating
trauma
25%
10%
9%
5%
KIA: Torso trauma, not
correctable
7%
1
%
KIA: Tension PTX
12%
31%
KIA: Torso trauma,
correctable
KIA: Extremity
exsanguination
DOW: Infection, shock
complications
Location of Death for Fatally
Wounded
Routine Use of Individual Body
Armor (IBA) by the U.S. Military
Standard currently issued U.S.
Army IBA ;
Note extra neck, shoulder, and
groin flaps ;
Use of IBA accounts for the
dramatic decrease in torso
wounds and the increase in the
percentage of extremity
wounds noted on the prior
slides ;
Note also the use of
polycarbonate protective
eyewear
Care for Patients in Body
Armor
• Even if no skin penetration, internal injuries
can occur from a bullet striking armor
– If hit on chest : lung contusion, rib fracture
possible  keep patient under observation, repeat
chest x-ray at 4 to 6 hours
– If lower chest or abdomen hit : may be spleen or
liver contusion or laceration
• Kevlar armor impossible to cut with standard
trauma scissors
Note these considerations apply to
care for civilian police
Battlefield Lessons : First LifeSaving Priorities in the Field
• Stop external bleeding
– Tourniquets have proven safe and effective
• Decompress tension pneumothorax in
the severely dyspneic patient
• Insert nasopharyngeal airway in the
unconscious patient
These same priorities would apply to
civilian mass casualty situations
What About Cardiopulmonary
Resuscitation (CPR) on the
Battlefield?
• CPR is useful in
…drowning
…hypothermia
…electrical shock
…but not during mass casualties
involving many truly injured people.
So combat medics are taught to not do
CPR in the battlefield environment
Battlefield Trauma Priorities in
General
• Life : priority over limb or sight
• Life threatening hemorrhage : priority over
airway and breathing
• Torso injury might have priority over limb
• Pulseless limb : priority over limb with
pulse
• Open fracture : priority over closed
These also apply to mass casualty
civilian practice
Military Medical Experience in
Iraq and Afghanistan
• Significant clinical experience in dealing
with blast and explosive injuries
• U.S. Military medical personnel have been
quick to seek and adopt new strategies in
treating hemorrhage, the leading cause of
preventable death
• Mortality rates are dramatically lower for the
current conflicts, and there are many
survivors of massive multiple trauma
Historical Comparison : U.S.
Military Medical Experience
Death Rates After Wounding :
• Revolutionary War : 42 %
• World War II : 30 %
• Korean War : ~25 %
• Vietnam War : ~25 %
• Persian Gulf War : ~25 %
• Global War on Terrorism : < 10 %
U.S. Military Medical
Experience
Medical Advances from the Global War On
Terror (GWOT) :
• Recognition and treatment of primary and
secondary blast injury
• Use of damage control surgery
• Whole blood and more clotting factors
• Tourniquets
• Hemostatic agents
• Hemostatic dressings
Injuries from Explosive
Munitions
• High percentage of current injuries, particularly
in Afghanistan
• Often severe, multisystem
• Multiple limb amputations
• Secondary injury from being thrown
• Eardrum rupture common
• Occult injuries may be present : “blast lung,”
bowel rupture, closed head injury with
sequelae
Blast Victim With Improvised
Tourniquets
Blast Injury Mechanisms
Blast Injury Categories
• Primary : direct effect of blast
overpressure on tissue
• Secondary : victim hit by flying objects
• Tertiary : “flying people” : being thrown
against fixed objects ; can cause severe
blunt trauma
• Miscellaneous : burns, crush, toxic
inhalations
Injuries to Suspect in the Blast
Victim
• Respiratory
– Pulmonary hemorrhage
– Alveolovenous fistula  air embolism
production
– Airway epithelial damage
• Circulatory
– Cardiac contusion
– Air embolism  myocardial ischemia
Blast Lung
Additional Injuries to Suspect
in the Blast Victim
• Digestive tract
– Gastrointestinal hemorrhage / perforation
– Retroperitoneal hemorrhage
– Ruptured spleen and / or liver
• Eye and Orbit
– Retinal air embolism
– Orbital fracture
Final Category of Injury to
Suspect in the Blast Victim
• Auditory System
– Tympanic membrane rupture
– Ossicular fractures
– Cochlear damage
Lesson Learned : Focus
Initially on Two Exams
• Ear exam
– If TM rupture  get chest x-ray, hold for 8
hour observation
– If TM not ruptured, no other symptoms 
conditionally exclude other primary blast
serious injury
• Pulse oximetry :  O2 saturation signals
early blast lung before symptoms
develop
Lesson Learned : Damage
Control Surgery
• Technique known for 20 years, but slow to be
accepted
• Central tenet : avoid “ The Deadly Triad” :
• Hypothermia
• Coagulopathy
• Metabolic acidosis
Each condition worsens both of the others
Principles of Damage Control
Surgery
• Quickly stop the bleeding
• Remove major contaminants
• Leave wound open to avoid abdominal
compartment syndrome
– “Pack ‘em and wrap ‘em”
• Transfer to Intensive Care Unit (ICU)
Damage Control Surgery :
Phase Two
• Resuscitate in ICU
– Normalize blood pressure
– Normalize body temperature
– Normalize coagulation factors
• Return to Operating Room in 12 to 18
hours for definitive surgery
Lessons Learned : Intravenous
Fluid Aspects for Hemostasis
• International Normalized Ratio (INR) > 1.5
on arrival is predictive of need for
massive transfusion (MT)
• Thawed fresh frozen plasma (FFP) is best
resuscitation fluid in MT
– Optimum ratio of plasma : crystalloid is 1:1
to avoid clotting factor dilution > 50 %
Hemostasis : More Intravenous
Aspect Lessons
• Limit crystalloid use in the field :
– Massive crystalloid infusion can have inflammatory,
acidotic, coagulopathy effects
– Hextend (a colloid ; hetastarch) preferable for field use
• Standard medic teaching is give 500 cc to hypovolemic
patients, repeat just once if ongoing hemorrhage
• Use fresh whole blood ; if not available, use one unit of FFP for
each unit of banked packed cells
• Early use of cryoprecipitate
• Recombinant Factor VIIa (rFVlla)
– Expensive, but appears to have saved a number of severely injured
patients
Lessons Learned : Wound
Hemostasis
• Tourniquets :
– Use liberally for any significant extremity
hemorrhage
– No adverse events seen
– Use early : “first resort not last resort”
– Every soldier carries at least one at all times
• The Combat Application Tourniquet (CAT) can be
applied by an injured soldier to himself using
only one hand
Combat Application Tourniquet™
Step 1 : Insert the wounded
extremity through the loop of
the self-adhering band
Step 2 : Pull the self-adhering
band tight and securely fasten it
back on itself.
Step 3 : Adhere the band around
the arm. Do not adhere the
band past the clip.
Step 5 : Lock the rod in place
with the Windlass Clip™.
Step 6 : Adhere the band over
the rod.
Lessons Learned : Wound
Hemostasis
• Hemostatic Dressings :
– Key to avoiding coagulopathy : control
bleeding early
– Primarily used for non-extremity
hemorrhage, but also useful in severely
mangled limbs
– Applied with pressure < 5 minutes, patient
“wrapped” and then transported
Choices for Topical
Hemostatic Agents
• HemCon (chitosan)
– Originally as bandage
– Now in roll that can be stuffed into wound
• QuikClot (initially available as a powder ; subsequently
marketed in a adherent package)
– Very exothermic (up to 147oF)
– Difficult to debride from wound due to adherence
• New Advanced Clotting Sponge (ACS)
– Gauze sack : is easily removed from wound
Lessons Learned : Field Use of
Medications
• Medics (and sometimes regular soldiers) are
supplied with oral antibiotics (gatifloxacin 400
mg per day currently used) and pain meds
(Celebrex 200 mg per day and / or
acetominophen)
– Note aspirin and nonsteroidals are contraindicated
in the field environment due to potential to worsen
bleeding from wounds
• Cefotetan 2 grams IV or IM for severely injured
Field antibiotic use has proven to
decrease infection rates
Summary of Medical Lessons
Learned from Afghanistan
• Use of body armor has changed the injury patterns seen
• Tourniquets can be lifesaving for exsanguinating extremity
wounds
• Early antibiotics (even in the field) are usually indicated
• Fresh whole blood and plasma are the best resuscitation fluids
• Damage control surgery is effective for the massively injured
• Blast victims may have multiple, initially occult, and delayed
manifesting injuries
Ruins of Darulaman Palace in south
Kabul
Hopeful sign from
a refugee camp in
Kabul
QUESTIONS ?
Thank You for Your Attention