Article 1
Who needs a tourniquet? And who does not? Lessons learned from a review of tourniquet use in the Russo-Ukrainian war. Butler F, Holcomb JB, Dorlac W, Gurney J, Inaba K, Jacobs L, et al. J Trauma and Acute Care Surg. 2024 Aug 1;97(2S Suppl 1):S45-S54.
The evolving international climate underscores the reality of a transforming battlefield. The Russo-Ukrainian conflict has provided critical insights into the nature of "large-scale combat operations" (LSCO), highlighting how such conflicts will reshape medical responses to battlefield injuries due to various tactical and logistical challenges. To prepare for this sobering reality, medical practices must be re-evaluated and adapted today. One critical practice that demands attention and refinement in an LSCO environment is the use of prehospital tourniquets.
Tourniquets gained prominence during the Iraq and Afghanistan wars as a life-saving intervention to prevent deaths from otherwise medically salvageable injuries. Their widespread adoption has undoubtedly saved countless lives by controlling life-threatening extremity bleeding. However, not all extremity wounds require such intervention. While tourniquet overuse in Iraq and Afghanistan did not result in significant morbidity, the extended evacuation times inherent in LSCO environments could amplify the adverse consequences of improperly applied or unnecessary tourniquets.
Butler et al. explored these challenges by evaluating the complications arising from tourniquet use in patients experiencing prolonged evacuation times during the Russo-Ukrainian war. The authors utilized a multifaceted approach, incorporating a review of the literature, expert input from a US/Ukraine Tourniquet Working Group meeting, and case studies to investigate the appropriate use of extremity tourniquets. The study emphasizes the complications associated with prolonged tourniquet application and proposes recommendations for refining training and protocols to optimize prehospital trauma care.
The authors’ literature review revealed that 75% of tourniquets applied during the early stages of the Russo-Ukrainian conflict were medically unnecessary—a significant concern given the extended time these devices remained in place. Unlike Iraq and Afghanistan, where evacuation times were typically under two hours, the tactical environment in Ukraine precluded rapid air evacuation. Consequently, Ukrainian casualties often endured evacuation delays of up to 21 hours, which heightened the risks of Prolonged Tourniquet Application Syndrome (PTAS), amputation, and acute kidney injury. One report documented a mean tourniquet application time of 205 minutes, with a 3.7% limb amputation rate.
The authors underscore the dual nature of tourniquets: their undeniable value in controlling severe hemorrhage and their potential for harm when improperly used or left in place too long. PTAS, in particular, poses a substantial threat in LSCO scenarios. To mitigate these risks, the authors advocate for enhanced training to improve injury assessment, early reassessment of applied tourniquets, and timely removal of those no longer necessary. They emphasize that all personnel likely to encounter casualties, not just medical professionals, should receive this training to ensure comprehensive readiness.
This article effectively highlights the urgent need to update trauma training and protocols in response to the prolonged evacuation times characteristic of LSCO environments. By integrating a thorough literature review, expert consensus, and contextual comparisons, the authors present a well-rounded discussion of tourniquet use and its associated challenges. The emphasis on practical recommendations, grounded in real-world conflict experiences, makes this article a valuable resource for both military and civilian trauma systems.
However, the study's limitations, including the lack of transparent, detailed data and its focus on military applications over broader civilian settings, warrant further exploration in future research. Despite these constraints, the findings offer critical guidance for military medical policymakers, leaders, and trauma care providers. They serve as a call to reassess current protocols and training, particularly as prolonged casualty care becomes increasingly common in combat scenarios. This work stands as a compelling reminder of the importance of nuanced medical interventions and a catalyst for improving trauma care in the complex operational environments of LSCO.
Article 2
The Golden Hour of Casualty Care: Rapid Handoff to Surgical Team is Associated With Improved Survival in War-injured US Service Members. Shackelford SA, Del Junco DJ, Mazuchowski EL, Kotwa RS, Remley MA, Keenan S, Gurney JM. Ann Surg. 2024 Jan 1;279(1):1-10.
"There is a golden hour between life and death. If you are critically injured you have less than 60 minutes to survive. You might not die right then; it may be three days or two weeks later -- but something has happened in your body that is irreparable." The quote by Dr. Cowley from 1975 continues to resonate in trauma literature today. Most battlefield deaths occur pre-hospital. The majority of those have been shown to be non-survivable, but there is a considerable proportion which are potentially survivable. Potentially survivable deaths almost uniformly result from hemorrhage with most of these due to truncal hemorrhage. Due to the austere environment, transport times to surgical capabilities is often prolonged. The goal of this study is to show that early transfer of care to a surgical team and early surgery will have a survival benefit over those who are delayed.
This was a retrospective, population-based cohort study evaluating injured US Service Members in the Iraq and Afghan wars. Analysis was limited to individuals who were presumed alive at evacuation request and had AIS scores ≥2. The data was obtained from the Department of Defense Trauma Registry between 2007 and 2015. The authors evaluated the timing of transfer of care to a surgical team as well as time to first surgery and the impact this had on mortality. Of the 5269 injured Service Members in this study, 728 succumbed to injuries within 30 days. Ninety-five percent of deaths occurred within 24 hours of injury. Additionally, 68% of deaths occurred within 1 hour of injury. Cox proportional hazards models were used to assess the two interventions: (1) handoff to surgical team and (2) initiation of surgery. The results of the study showed that transfer of care for a severely injured US Service Member within one hour of injury resulted in a reduction of mortality by 66%. Likewise, for those personnel requiring emergency surgery, there was a 60% decrease in mortality for those who were able to undergo surgery within one hour of injury.
There are limitations to this study. First is its retrospective nature, however given the current military operations, prospective studies are not possible. There are biases which are inherent to this type of research which are well described by the authors in the paper. Finally, over half of the patients requiring emergent surgery had incomplete event times. Sensitivity analyses were included in the supplemental content.
This is the first study to look at survival related to the timing of injured US Service Members receiving care from a surgical team. The results show there is a significant mortality reduction in those who are presented to a surgical team early. Additionally, of those who require emergent surgery, early initiation of surgery has a significant mortality benefit. This should come as no surprise as previous studies have shown that potentially survivable battlefield deaths are commonly due to truncal hemorrhage. In urban civilian trauma, there is expeditious transport of critically injured patients to an academic trauma center. In combat, there are several limitations with medical evacuation (availability of resources, accessibility to the injured, safety of evacuation, distance to the treatment facility, etc.) which delay trauma care. Therefore, it is often beneficial to bring the surgical care forward to the patient rather than attempt a prolonged transport. Forward surgical teams have been used in combat since the beginning of the Global War on Terror. It is important we do not forget the lessons learned from prior conflicts during this time of reduced combat activity. Through the utilization of military-civilian partnerships and trauma training courses, competencies of military surgeons and surgical teams can be maintained.
Article 3
A 20-year retrospective analysis of deep venous thrombosis and pulmonary embolism among combat casualties requiring damage-control laparotomy at US military Role 2 surgical units. Cobler-Lichter MD, Collie BL, Delamater JM, Shagabayeve L, Lyons NB, et al. J Trauma Acute Care Surg. 2024 Aug 1;97(2S Suppl 1):S55-S59.
Venous thromboembolism is a significant contributor to trauma patient morbidity secondary to trauma coagulopathy. This is especially true within the combat trauma population, where high ISS, frequent MTP requirements, high incidence of traumatic amputation, and injury secondary to explosive devices all increase the risk of VTE. Compounding this is the fact that many patients require prolonged transport both within theater and out of theater as they move through echelons of care, which itself is known to increase VTE risk. Nonetheless, there is still a knowledge gap on the incidence of VTE in combat casualties who required damage control laparotomy at Role 2/forward deployed surgical units. Cobler-Lichter et al. attempt to address this gap.
This is a retrospective registry-based analysis evaluating over 20 years of Department of Defense Trauma Registry (DoDTR) data from 2002-2023. Patients were limited to US military casualties who underwent damage-control laparotomies at a Role 2 military treatment facility (MTF), and all deaths were excluded. The primary outcome of interest was VTE, defined as a DVT or a PE. Of 288 patients identified, 35 patients expired prior to reaching definitive care. Of the remaining 253 patients, 10.3% were diagnosed with a DVT and 7.1% were diagnosed with a PE. Of note, patients who developed VTE more often were treated at multiple MTFs. Patients who received MTP also had higher rates of VTE than those who did not (26.7% vs 10.2%, p< 0.001).
There are a few limitations to consider. First is its retrospective nature utilizing the DoDTR. There are inherent difficulties working with a retrospective database such as potentially inaccurate or incomplete data. This is especially inherent to the DoDTR given the diverse methods of documentation for the military patient that may be required when working within an austere and often combat-involved environment. Another limitation that needs to be kept in mind is the fact that military patients are a unique population, with different exposures and injury mechanisms that would not be found in a civilian setting (e.g. explosives, high mechanism penetrating injuries), and as such, have no real control group to compare to. These limitations are well described and well addressed by the authors.
Nonetheless, this is a well written paper that highlights the high incidence of VTE in military trauma patients. The interesting finding of higher VTE rates at higher echelons of care is something to be cognizant of and requires further investigation, and this paper provides some groundwork to investigate the utility of screening ultrasounds for VTE at Role 3 or higher MTFs. The proposal to utilize checklists as patients transition between echelons of care and different MTFs is well received to ensure that chemoprophylaxis is started as soon as feasibly possible in this high-risk population, in line with current clinical practice guidelines. This will ensure that treatment plans are not misunderstood during transfers and that critical items are not missed as patients move through the military health system from damage control laparotomy at a Role 2 MTF through to definitive and tertiary care at Role 4 and 5 MTFs.
