Military

Thoracic trauma in military settings: a review of current practices and recommendations.

Mansky R, Scher C.

Curr Opin Anaesthesiol. 2019 Apr;32(2):227-233

Rationale for inclusion: CPG. Reviews basic principles for blunt chest trauma management, including airway management, ECMO, EDT.

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Re-examination of a Battlefield Trauma Golden Hour Policy.

Howard JT, Kotwal RS, Santos AR, Martin MJ, Stockinger ZT

J Trauma Acute Care Surg. 2017 Oct 16.

Rationale for inclusion: Examination of eliminating preventable death, killed in action (KIA) via registry review from OEF.

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Prehospital application of hemostatic agents in Iraq and Afghanistan.

Schauer SG, April MD, Naylor JF, Maddry JK, Arana AA, Dubick MA, Fisher AD, Cunningham CW, Pusateri AE.

Prehosp Emerg Care. 2018 Sep-Oct;22(5):614-623

Rationale for inclusion: Reviewed use of hemostatics between 2007-2016 (kaolin- Quikclot, chitosan- Hemcon and Celox). Patients receiving hemostatic agent- higher ISS, more likely to suffer GSW, higher AIS for abdomen and extremity. No difference in mortality.

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Damage control resuscitation.

Cap AP, Pidcoke HF, Spinella P, Strandenes G, Borgman MA, Schreiber M, Holcomb J, Tien HC, Beckett AN, Doughty H, Woolley T, Rappold J, Ward K, Reade M, Prat N, Ausset S, Kheirabadi B, Benov A, Griffin EP, Corley JB, Simon CD, Fahie R, Jenkins D, Eastridge BJ, Stockinger Z

Mil Med. 2018 Sep 1;183(suppl_2):36-43

Rationale for inclusion: Reinforces principles of blood transfusion, minimizing crystalloid, hypotensive resuscitation until hemorrhage control, TXA, avoidance of acidosis and hypothermia. Reviews indicators of need for MTP (vitals, injury, labs, imaging). Discusses storage and usage of blood components.

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A US military Role 2 forward surgical team database study of combat mortality in Afghanistan.

Kotwal RS, Staudt AM, Mazuchowski EL, Gurney JM, Shackelford SA, Butler FK, Stockinger ZT, Holcomb JB, Nessen SC, Mann-Salinas EA.

J Trauma Acute Care Surg. 2018 Sep;85(3):603-612.

Rationale for inclusion: Large Role 2 registry review.

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Neurosurgery and medical management of severe head injury.

McCafferty RR, Neal CJ, Marshall SA, Pamplin JC, Rivet D, Hood BJ, Cooper PB, Stockinger Z.

Mil Med. 2018 Sep 1;183(suppl_2):67-72.

Rationale for inclusion: CPG. Reviews basic principles for TBI management, including fluids, sedation, medical mgmt of ICH.

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Wartime vascular injury.

Rasmussen T, Stockinger Z, Antevil J, White C, Fernandez N, White J, White P.

Military Medicine, 183, 9/10:10, 2018

Rationale for inclusion: CPG. Provides helpful algorithm for addressing extremity vascular trauma for the non-vascular surgery. Reviews hard and soft signs and ABI. Shunt is mainstay for far forward care.

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Aural blast injury/acoustic trauma and hearing loss

Esquivel CR, Parker M, Curtis K, Merkley A, Littlefield P, Conley G, Wise S, Feldt B, Henselman L, Stockinger Z.

Mil Med. 2018 Sep 1;183(suppl_2):78-82.

Rationale for inclusion: CPG. Reviews recommendations for evaluating hearing damage and indications for ENT referral.

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Burn casualty care in the deployed setting

Driscoll IR, Mann-Salinas EA, Boyer NL, Pamplin JC, Serio-Melvin ML, Salinas J, Borgman MA, Sheridan RL, Melvin JJ, Peterson WC, Graybill JC, Rizzo JA, King BT, Chung KK, Cancio LC, Renz EM, Stockinger ZT.

Military Medicine, 183, 9/10:16, 2018

Rationale for inclusion: CPG. Reviews recommendations for determining burn size and initial resuscitation calculation. Unique to military with lack of access to subspecialists, discusses mgmt of ophthalmic injuries, inhalation injuries.

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Amputation: evaluation and treatment

Gordon W, Balsamo L, Talbot M, Osier C, Johnson A, Shero J, Potter B, Stockinger ZT.

Military Medicine, 183, 9/10:112, 2018

Rationale for inclusion: CPG for evaluation and considerations for amputation.

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Management of suspected tension pneumothorax in Tactical Combat Casualty Care: TCCC guidelines change 17-02.

Butler FK Jr, Holcomb JB, Shackelford S, Montgomery HR, Anderson S, Cain JS, Champion HR, Cunningham CW, Dorlac WC, Drew B, Edwards K, Gandy JV, Glassberg E, Gurney J, Harcke T, Jenkins DA, Johannigman J, Kheirabadi BS, Kotwal RS, Littlejohn LF, Martin M, Mazuchowski EL, Otten EJ, Polk T, Rhee P, Seery JM, Stockinger Z, Torrisi J, Yitzak A, Zafren K, Zietlow SP.

Journal of Special Operations Medicine. 18(2):19-35, Summer 2018.

Rationale for inclusion: TCCC Guideline update. Designates the location at which NDC should be performed as either the lateral site (5th ICS, ant ax line) or the anterior site (2nd ICS, midclavicular line). Risk of bleeding with anterior site. ATLS recommends lateral site as 1st choice. *Essentially equivocal- no documented complications from anterior approach, no clear benefit to lateral site being more successful.

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Epidemiology of trauma-related Infections among a combat casualty cohort after initial hospitalization:The Trauma Infectious Disease Outcomes Study.

Tribble DR, Krauss MR, Murray CK, Warkentien TE, Lloyd BA, Ganesan A, Greenberg L, Xu J, Li P, Carson ML, Bradley W, Weintrob AC

Surg Infect (Larchmt). 2018 Jul;19(5):494-503

Rationale for inclusion: Retrospective observational study of 3 years of service members evacuated from theater after combat injury and their infection rates and types after initial hospitalization.

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Combat surgical workload in Operation Iraqi Freedom and Operation Enduring Freedom: The definitive analysis.

Turner CA, Stockinger ZT, Gurney JM

J Trauma Acute Care Surg. 2017 Jul;83(1):77-83.

Rationale for inclusion: DoDTR comprehensive Review of all surgical procedures performed at R2 and R3 facilities in OIF, OEF.

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The effect of prehospital transport time, injury severity, and blood transfusion on survival of US military casualties in Iraq.

Kotwal RS, Scott LLF, Janak JC, Tarpey BW, Howard JT, Mazuchowski EL, Butler FK, Shackelford SA, Gurney JM, Stockinger ZT

J Trauma Acute Care Surg. 2018 Jul;85(1S Suppl 2):S112-S121.

Rationale for inclusion: Data from OIF, prehospital blood transfusion and battlefield survival.

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Recent advances in austere combat surgery: Use of aortic balloon occlusion as well as blood challenges by special operations medical forces in recent combat operations.

Northern DM, Manley JD, Lyon R, Farber D, Mitchell BJ, Filak KJ, Lundy J, DuBose JJ, Rasmussen TE, Holcomb JB

J Trauma Acute Care Surg. 2018 Jul;85(1S Suppl 2):S98-S103

Rationale for inclusion: Largest review of REBOA in far forward DCR. 19/20 were successful.

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Intramuscular tranexamic acid in tactical and combat settings.

Vu EN; Wan WCY; Yeung TC; Callaway DW.

Journal of Special Operations Medicine. 18(1):62-68, Spring 2018.

Rationale for inclusion: Support for TXA in the combat and tactical setting.

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Early infections complicating the care of combat casualties from Iraq and Afghanistan.

Weintrob AC , Murray CK , Xu J , Krauss M , Bradley W , Warkentien TE, Lloyd BA, Tribble DR

Surg Infect (Larchmt). 2018 Apr;19(3):286-297.

Rationale for inclusion: Retrospective observational study of 3 years of service members evacuated from theater after combat injuries, their early infection rate, infection types and risk factors for infection.

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Association of prehospital blood product transfusion during medical evacuation of combat casualties in Afghanistan with acute and 30-day survival.

Shackelford SA, Del Junco DJ, Powell-Dunford N, Mazuchowski EL, Howard JT, Kotwal RS, Gurney J, Butler FK Jr, Gross K, Stockinger ZT.

JAMA. 2017 Oct 24;318(16):1581-1591.

Rationale for inclusion: Retrospective cohort of over 500 military casualties which showed prehospital transfusion was associated with improved survival at 24 hours and 30 days.

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Association of Prehospital Blood Product Transfusion During Medical Evacuation of Combat Casualties in Afghanistan With Acute and 30-Day Survival.

Shackelford SA, Del Junco DJ, Powell-Dunford N, Mazuchowski EL, Howard JT, Kotwal RS, Gurney J, Butler FK, Gross K, Stockinger ZT.

JAMA. 2017 Oct 24;318(16):1581-1591.

Rationale for inclusion: Data from OEF, prehospital blood transfusion and battlefield survival.

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Expeditionary Resuscitation Surgical Team: the US Army's initiative to provide damage control resuscitation and surgery to forces in austere settings.

D'Angelo M, Losch J, Smith B, Geslak M, Compton S, Wofford K, Seery JM, Morrison M, Wedmore I, Paimore J, Gross K, Cuenca PJ, Welder MD.

Journal of Special Operations Medicine. 17(4):76-79, Winter 2017.

Rationale for inclusion: Discusses one of the most recent advances in far forward care, the highly mobile ERST.

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Junctional hemorrhage control for tactical combat casualty care

Kotwal RS; Butler FK Jr.

Wilderness & Environmental Medicine. 28(2S):S33-S38, 2017 Jun.

Rationale for inclusion: Reviews studies on different junctional tourniquets available.

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Fluid resuscitation in tactical combat casualty care: yesterday and today.

Butler FK Jr.

Wilderness & Environmental Medicine. 28(2S):S74-S81, 2017 Jun.

Rationale for inclusion: Review timeline of updates in resuscitation. Previously 2L crystalloid was the choice for initial resuscitation. New guidelines- emphasize whole blood, followed by component therapy, with crystalloid as last choice. No fluids if radial pulse strong and normal mental status.

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Dismounted Complex Blast Injuries: A Comprehensive Review of the Modern Combat Experience.

Cannon JW, Hofmann LJ, Glasgow SC, Potter BK, Rodriguez CJ, Cancio LC, Rasmussen TE, Fries CA, Davis MR, Jezior JR, Mullins RJ, Elster EA.

J Am Coll Surg. 2016 Oct;223(4):652-664.e8.

Rationale for inclusion: Dismounted Complex Blast Injury is one of the most challenging injury patterns to emerge from OEF and OIF. This paper reviews the historical perspective, demographics, initial resuscitation and management as well as complications.

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Lessons learned for the resuscitation of traumatic hemorrhagic shock.

Spinella PC; Perkins JG; Cap AP.

US Army Medical Department Journal. (2-16)37-42, 2016 Apr-Sep.

Rationale for inclusion: Early hemostatic resuscitation with blood, minimize crystalloids. Permissive hypotension but NOT for prolonged field care. Coagulopathy is frequently present early after trauma. Over-resuscitation with crystalloid has significant complications.

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Negative pressure wound therapy in the management of combat wounds: A critical review.

Maurya S, Bhandari PS.

Advances in Wound Care. 5(9):379-389, 2016 Sep 01.

Rationale for inclusion: Reviewed benefit of NPWT- military wounds are different from civilian wounds- much more contaminated with dirt, foreign matter, bioburden. Primary closure is not recommended, and wounds need aggressive irrigation and debridement to avoid infection. NPWT helps to provide temporary wound cover during the interim period of debridement and wound closure.

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Augmentation of point of injury care: Reducing battlefield mortality-The IDF experience.

Benov Avi, Elon G, Baruch EN, Avi S, Gilad T, Moran L, Itay Z, Ram S, Tarif B, David D, Avraham Y, Yitshak K

Injury. 2016 May;47(5):993-1000

Rationale for inclusion: Information from IDF MC on incorporation of a physician or paramedic into each fighting company, implementation of new CPGs, introduction of new approaches for extremity haemorrhage control and Remote Damage Control Resuscitation at point of injury (POI) using single donor reconstituted FDP and TXA. Impact on outcomes.

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Extending the golden hour: Partial resuscitative endovascular balloon occlusion of the aorta in a highly lethal swine liver injury model.

Russo RM, Williams TK, Grayson JK, Lamb CM, Cannon JW, Clement NF, Galante JM, Neff LP

J Trauma Acute Care Surg. 2016 Mar;80(3):372-8; discussion 378-80.

Rationale for inclusion: Partial REBOA in swine model may be useful with less reperfusion injury.

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The effect of a golden hour policy on the morbidity and mortality of combat casualties.

Kotwal RS, Howard JT, Orman JA, Tarpey BW, Bailey JA, Champion HR, Mabry RL, Holcomb JB, Gross KR.

JAMA Surg. 2016 Jan;151(1):15-24.

Rationale for inclusion: Although only cited 8 times, this is a relatively recent paper and addressed a controversial topic of the "Golden Hour." This study presents data accrued before and after the mandate in 2009 for transport to surgical care within 60 minutes.

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Resuscitative endovascular balloon occlusion of the aorta for hemorrhage control: Past, present, and future

Belenkiy, SM, Batchinsky AI, Rasmussen TE, Cancio LC

Journal of Trauma and Acute Care Surgery. 79(4 Supp 2):S236-S242, October 2015.

Rationale for inclusion: Discusses the evolution of REBOA, and the potential for implementation in far forward deployed environments. Origin in the Korean War. More experience developed from non-trauma emergencies (GI bleed, ruptured AAA). Multiple animal studies comparied REBOA and EDT for aortic occlusions for hemorrhagic shock. Ongoing innovation for allow implementation in far forward environment.

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Contemporary wars and their contributions to vascular injury management.

Asensio JA, Petrone P, Perez-Alonso A, Verde JM, Martin MJ, Sanchez W, Smith S, Marini CP.

European Journal of Trauma & Emergency Surgery. 41(2):129-42, 2015 Apr.

Rationale for inclusion: Reviews advances in management of vascular injury associated with wartime "lessons learned", starting in 1904. 1946- DeBakey and Simone emphasized expeditious restoration of blood flow. 1950- Korea, more abx utilized, improved limb salvage rates.

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Prehospital and en route analgesic use in the combat setting: a prospectively designed, multicenter, observational study.

Petz LN, Tyner S, Barnard E, Ervin A, Mora A, Clifford J, Fowler M, Bebarta VS.

Military Medicine. 180(3 Suppl):14-8, 2015 Mar.

Rationale for inclusion: Ketamine has the benefit of no hypotension or respiratory depression. Can minimize opiate requirement. Prehospital, ketamine was the most commonly used analgesic drug; ketamine/ morphine were the most frequently observed combination. IV route used for 55% of drug adminstrations

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Freeze-dried plasma at the point of injury: from concept to doctrine.

Glassberg E, Nadler R, Gendler S, Abramovich A, Spinella PC, Gerhardt RT, Holcomb JB, Kreiss Y.

Shock. 40(6):444-50, 2013 Dec.

Rationale for inclusion: Discussed the implementation of freeze dried plasma in austere environments

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Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom: increased plasma and platelet use correlates with improved survival.

Pidcoke HF; Aden JK; Mora AG; Borgman MA; Spinella PC; Dubick MA; Blackbourne LH; Cap AP.

The Journal of Trauma and Acute Care Surgery. 73(6 Suppl 5):S445-52, 2012 Dec.

Rationale for inclusion: Reviewed patients who received transfusion (2003-2012). Evaluate impact of updated CPGs. Decreased mortality with balanced transfusion. Support benefits of DCR, suggests platelet dysfunction may contribute to coagulopathy.

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Death on the battlefield (2001-2011): Implications for the future of combat casualty care.

Eastridge BJ, Mabry RL, Seguin P, Cantrell J, Tops T, Uribe P, Mallett O, Zubko T, Oetjen-Gerdes L, Rasmussen TE, Butler FK, Kotwal RS, Holcomb JB, Wade C, Champion H, Lawnick M, Moores L, Blackbourne LH.

J Trauma Acute Care Surg. 2012 Dec;73(6 Suppl 5):S431-7.

Rationale for inclusion: This was a large analysis of pre-medical treatment facility (MTF) deaths. This study identified that the vast majority of potentially surviveable pre-MTF deaths were due to hemorrhage and further classified the site of the lethal hemorrhage.

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Evaluation of military trauma system practices related to damage-control resuscitation.

Palm K, Apodaca A, Spencer D, Costanzo G, Bailey J, Blackbourne LH, Spott MA, Eastridge BJ.

J Trauma Acute Care Surg. 2012 Dec;73(6 Suppl 5):S459-64.

Rationale for inclusion: This is a pre-post analysis study on the implemenation of the damage control resusctitation guideline implementation in the joint theater trauma system. Effective implementation and adherence is of the guideline is associated with improved compliance with balanced component transfusion and decreased practice variability.

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Invasive mold infections following combat-related injuries.

Warkentien T, Rodriguez C, Lloyd B, Wells J, Weintrob A, Dunne JR, Ganesan A, Li P, Bradley W, Gaskins LJ, Seillier-Moiseiwitsch F, Murray CK, Millar EV, Keenan B, Paolino K, Fleming M, Hospenthal DR, Wortmann GW, Landrum ML, Kortepeter MG, Tribble DR; Infectious Disease Clinical Research Program Trauma Infectious Disease Outcomes Study Group.

Clin Infect Dis. 2012 Dec;55(11):1441-9.

Rationale for inclusion: This is the first description of the clnical risk factors associated with an aggressive combat-related fungal wound infection related to blast injury. From these clinical factors described the JTTS developed practice guidelines.

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Military application of tranexamic acid in trauma emergency resuscitation (MATTERs) study.

Morrison JJ, Dubose JJ, Rasmussen TE, Midwinter MJ.

Arch Surg. 2012 Feb;147(2):113-9.

Rationale for inclusion: This is the first military study on the use of TXA in conjunction with blood component-based resuscitation in combat casualties. Improved survival was seen in those patients who received TXA and was more prominent in those requiring massive transfusion.

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Eliminating preventable death on the battlefield.

Kotwal RS, Montgomery HR, Kotwal BM, Champion HR, Butler FK Jr, Mabry RL, Cain JS, Blackbourne LH, Mechler KK, Holcomb JB.

Arch Surg. 2011 Dec;146(12):1350-8.

Rationale for inclusion: This is the first review of command driven TCCC guidelines and a prehospital trauma registry and has resulted in unprecedented reduction in preventable combat deaths. This is now the model for combat casualty care on the battlefield.

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Early decompressive craniectomy for severe penetrating and closed head injury during wartime.

Bell RS, Mossop CM, Dirks MS, Stephens FL, Mulligan L, Ecker R, Neal CJ, Kumar A, Tigno T, Armonda RA.

Neurosurg Focus. 2010 May;28(5):E1.

Rationale for inclusion: This study is a large review of combat patients with head injuries who underwent decompressive craniectomy for severe TBI in theater. Craniectomy was employed for those with worse initial presentations and was noted to be associated with improved outcomes over time.

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Military traumatic brain and spinal column injury: a 5-year study of the impact blast and other military grade weaponry on the central nervous system.

Bell RS, Vo AH, Neal CJ, Tigno J, Roberts R, Mossop C, Dunne JR, Armonda RA.

J Trauma. 2009 Apr;66(4 Suppl):S104-11.

Rationale for inclusion: This is a large retrospective review of combat injured patients evacuated to a military Role V hospital for neurosurgical evaluation. This study details the epidemiology of combat related neurologic injury in the recent wars in Iraq and Afghanistan.

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An analysis of in-hospital deaths at a modern combat support hospital.

Martin M, Oh J, Currier H, Tai N, Beekley A, Eckert M, Holcomb J.

J Trauma. 2009 Apr;66(4 Suppl):S51-60; discussion S60-1.

Rationale for inclusion: This review of a CSH experience for potentially preventable deaths identified areas for improvement to include delays in prehospital care and in hospital hemorrhage control.

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Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries.

Spinella PC, Perkins JG, Grathwohl KW, Beekley AC, Holcomb JB.

J Trauma. 2009 Apr;66(4 Suppl):S69-76.

Rationale for inclusion: The military experience with fresh whole blood transfusions is largely out of necessity due to the inability to store adequate component products at forward surgical units. This retrospective study demonstrates that there is a survival advantage to WFWB transfusion in patients with hemorrhagic shock.

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An evaluation of the impact of apheresis platelets used in the setting of massively transfused trauma patients.

Perkins JG, Cap AP, Spinella PC, Blackbourne LH, Grathwohl KW, Repine TB, Ketchum L, Waterman P, Lee RE, Beekley AC, Sebesta JA, Shorr AF, Wade CE, Holcomb JB.

J Trauma. 2009 Apr;66(4 Suppl):S77-84; discussion S84-5.

Rationale for inclusion: This study represents a large cohort of patients treated at a combat hosptial in Iraq. Those requiring massive transfusion who received apheresed platelets in high aPLT:RBC ratio > 1:8 had improved survival.

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Survival with emergency tourniquet use to stop bleeding in major limb trauma.

Kragh JF Jr, Walters TJ, Baer DG, Fox CJ, Wade CE, Salinas J, Holcomb JB.

Ann Surg. 2009 Jan;249(1):1-7.

Rationale for inclusion: This is a relatively large study on the use of tourniquets in a combat hospital. The results are striking in that tourniquet use when applied early (before evidence of shock) was associated with survival in 90% versus 10% when applied in those already in shock.

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Increased mortality associated with the early coagulopathy of trauma in combat casualties.

Niles SE, McLaughlin DF, Perkins JG, Wade CE, Li Y, Spinella PC, Holcomb JB.

J Trauma. 2008 Jun;64(6):1459-63; discussion 1463-5.

Rationale for inclusion: In this retrospective review of combat trauma patients, acute coagulopathy was associated with mortality, similar to civilian trauma patients.

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QuikClot use in trauma for hemorrhage control: case series of 103 documented uses.

Rhee P, Brown C, Martin M, Salim A, Plurad D, Green D, Chambers L, Demetriades D, Velmahos G, Alam H.

J Trauma. 2008 Apr;64(4):1093-9.

Rationale for inclusion: This is unique study in that both military and civilian, surgeons and pre-hospital providers used Quickclot for hemorrhage control in over 100 cases. It was found to effective, especially in the pre-hospital setting. Only 3 cases of burns were encountered.

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Practical use of emergency tourniquets to stop bleeding in major limb trauma.

Kragh JF Jr, Walters TJ, Baer DG, Fox CJ, Wade CE, Salinas J, Holcomb JB.

J Trauma. 2008 Feb;64(2 Suppl):S38-49; discussion S49-50.

Rationale for inclusion: This study on tourniquet use on combat injured patients provides data that supports very minimal morbidity associated with tourniquet use including nerve palsy and no limb loss due to tourniquet use in this study.

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Prehospital tourniquet use in Operation Iraqi Freedom: effect on hemorrhage control and outcomes.

Beekley AC, Sebesta JA, Blackbourne LH, Herbert GS, Kauvar DS, Baer DG, Walters TJ, Mullenix PS, Holcomb JB; 31st Combat Support Hospital Research Group.

J Trauma. 2008 Feb;64(2 Suppl):S28-37; discussion S37.

Rationale for inclusion: This is another study on tourniquet use at a combat hospital that further supports the use of tourniquets to aid in hemorrhage control in extremity injuries. No adverse outcomes were cited, and tourniquet use might have positively impacted potentially preventable deaths.

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The ratio of fibrinogen to red cells transfused affects survival in casualties receiving massive transfusions at an army combat support hospital.

Stinger HK, Spinella PC, Perkins JG, Grathwohl KW, Salinas J, Martini WZ, Hess JR, Dubick MA, Simon CD, Beekley AC, Wolf SE, Wade CE, Holcomb JB.

J Trauma. 2008 Feb;64(2 Suppl):S79-85; discussion S85.

Rationale for inclusion: In combat trauma patients who were found to need massive transfusion and also received higher ratios of fibrinogen:RBC there was increased survival.

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Joint theater trauma system implementation of burn resuscitation guidelines improves outcomes in severely burned military casualties.

Ennis JL, Chung KK, Renz EM, Barillo DJ, Albrecht MC, Jones JA, Blackbourne LH, Cancio LC, Eastridge BJ, Flaherty SF, Dorlac WC, Kelleher KS, Wade CE, Wolf SE, Jenkins DH, Holcomb JB.

J Trauma. 2008 Feb;64(2 Suppl):S146-51; discussion S151-2.

Rationale for inclusion: Prospectively collected data on burn casualties was compared to patients treated in theater prior to the Burn Resusciation Guidelines. This paper demonstrated the improved mortality associated with implementation of the guidelines, but more importantly it highlighted the implementation and effectiveness of the Clinical Practice Guidelines.

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Amputations in U.S. military personnel in the current conflicts in Afghanistan and Iraq.

Stansbury LG, Lalliss SJ, Branstetter JG, Bagg MR, Holcomb JB.

J Orthop Trauma. 2008 Jan;22(1):43-6.

Rationale for inclusion: This study from early in the Afghanistan and Iraq wars reviewed over 5000 patients with limb injuries. This is a detailed epidemiological review on the injury patters, level of amputations, and mechanism of injury.

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Tactical combat casualty care 2007: evolving concepts and battlefield experience.

Butler FK Jr, Holcomb JB, Giebner SD, McSwain NE, Bagian J.

Mil Med. 2007 Nov;172(11 Suppl):1-19.

Rationale for inclusion: This review describes the development and evolution of the TCCC guidelines from inception in 1996 through continuous updates organized by the Committee on TCCC.

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Risks associated with fresh whole blood and red blood cell transfusions in a combat support hospital.

Spinella PC, Perkins JG, Grathwohl KW, Repine T, Beekley AC, Sebesta J, Jenkins D, Azarow K, Holcomb JB; 31st Combat Support Hospital Research Working Group.

Crit Care Med. 2007 Nov;35(11):2576-81.

Rationale for inclusion: The use of WFWB transfusion, especially in combat resusciation, is known to incur a survival advantage. Concerns over safety of FWB tranfsusion exist. This study shows that the risk of infection disease transmission can be minimized for FWB transfusion in a pre-screened miiltary combat environment.

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The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital.

Borgman MA, Spinella PC, Perkins JG, Grathwohl KW, Repine T, Beekley AC, Sebesta J, Jenkins D, Wade CE, Holcomb JB.

J Trauma. 2007 Oct;63(4):805-13.

Rationale for inclusion: This retrospective review of combat patients requiring massive tranfusion showed that those who received high plasma to PRBC ratios had improved survival. This is clearly a landmark paper that significantly impacted both military and civilian blood resuscitation therapy and massive transfusion protocols.

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Early predictors of massive transfusion in combat casualties.

Schreiber MA, Perkins J, Kiraly L, Underwood S, Wade C, Holcomb JB.

J Am Coll Surg. 2007 Oct;205(4):541-5.

Rationale for inclusion: This is retrospective review of combat patients requiring massive transfusion. Massive transfusion in this group was associated with higher mortality, and variable present early upon admission can predict the need for massive transfusion.

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Infectious complications of open type III tibial fractures among combat casualties.

Johnson EN, Burns TC, Hayda RA, Hospenthal DR, Murray CK.

Clin Infect Dis. 2007 Aug 15;45(4):409-15.

Rationale for inclusion: High energy combat wounds frequently resulted in open tibial fractures. Infectious complications were common and even associated with limb amputations as described in this paper.

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An outbreak of multidrug-resistant Acinetobacter baumannii-calcoaceticus complex infection in the US military health care system associated with military operations in Iraq.

Scott P, Deye G, Srinivasan A, Murray C, Moran K, Hulten E, Fishbain J, Craft D, Riddell S, Lindler L, Mancuso J, Milstrey E, Bautista CT, Patel J, Ewell A, Hamilton T, Gaddy C, Tenney M, Christopher G, Petersen K, Endy T, Petruccelli B.

Clin Infect Dis. 2007 Jun 15;44(12):1577-84.

Rationale for inclusion: This study investigated an outbreak Acinetobacter at US field hospitals during recent military operations. The results of this investigation have been widely cited in the development of infection control guidelines.

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Causes of death in U.S. Special Operations Forces in the global war on terrorism: 2001-2004.

Holcomb JB, McMullin NR, Pearse L, Caruso J, Wade CE, Oetjen-Gerdes L, Champion HR, Lawnick M, Farr W, Rodriguez S, Butler FK.

Ann Surg. 2007 Jun;245(6):986-91.

Rationale for inclusion: This is the initial paper on modern battlefield deaths. It not only describes the mechanism of injury but also discussed the causes of potentially surviveable deaths.

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Petersen K, Riddle MS, Danko JR, Blazes DL, Hayden R, Tasker SA, Dunne JR.

Ann Surg. 2007 May;245(5):803-11.

Rationale for inclusion: This is a retrospective review from the Iraq war. In a short period of time a relatively large number of patients with combat related infections were seen. This paper describes the characteristics of these infections as they relate to the types of war wounds.

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Characterization of extremity wounds in Operation Iraqi Freedom and Operation Enduring Freedom.

Owens BD, Kragh JF Jr, Macaitis J, Svoboda SJ, Wenke JC.

J Orthop Trauma. 2007 Apr;21(4):254-7.

Rationale for inclusion: Extremity wounds have been commonly reported in the most recent wars. This is an epidemiological study of a large cohort of combat injured patients with extremity injuries describing anatomic location, mechanisms of injury, and characteristics of the injuries.

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Damage control resuscitation: directly addressing the early coagulopathy of trauma.

Holcomb JB, Jenkins D, Rhee P, Johannigman J, Mahoney P, Mehta S, Cox ED, Gehrke MJ, Beilman GJ, Schreiber M, Flaherty SF, Grathwohl KW, Spinella PC, Perkins JG, Beekley AC, McMullin NR, Park MS, Gonzalez EA, Wade CE, Dubick MA, Schwab CW, Moore FA, Champion HR, Hoyt DB, Hess JR.

J Trauma. 2007 Feb;62(2):307-10.

Rationale for inclusion: Although this is a commentary, it represents one of the earliest and most recognized discussions of damage control resusctation.

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Trauma system development in a theater of war: experiences from Operation Iraqi Freedom and Operation Enduring Freedom.

Eastridge BJ, Jenkins D, Flaherty S, Schiller H, Holcomb JB.

J Trauma. 2006 Dec;61(6):1366-72; discussion 1372-3.

Rationale for inclusion: This is the first detailed description of the implementaion of the Joint Theater Trauma System. The implementation of the system helped identify multiple systems issues for the improvement of patient care including patient transfer to the appropriate level of care, the development of a trauma registry and performance improvement.

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The use of temporary vascular shunts as a damage control adjunct in the management of wartime vascular injury.

Rasmussen TE, Clouse WD, Jenkins DH, Peck MA, Eliason JL, Smith DL.

J Trauma. 2006 Jul;61(1):8-12; discussion 12-5.

Rationale for inclusion: This study details over 120 combat injured patients with vascular injuries treated at far forward locations. Temporary vascular shunts were used in the management of more than 50% with resultant good outcomes.

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The impact of hypothermia on trauma care at the 31st combat support hospital.

Arthurs Z, Cuadrado D, Beekley A, Grathwohl K, Perkins J, Rush R, Sebesta J.

Am J Surg. 2006 May;191(5):610-4.

Rationale for inclusion: This study represented a large cohort of patients (2848) who presented to a CSH over a 12 month period. 18% were hypothermic on presentation, and hypothermia was an independent predictor of damage control laparotomy and mortality.

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Contemporary management of wartime vascular trauma.

Fox CJ, Gillespie DL, O'Donnell SD, Rasmussen TE, Goff JM, Johnson CA, Galgon RE, Sarac TP, Rich NM.

J Vasc Surg. 2005 Apr;41(4):638-44.

Rationale for inclusion: This paper is from early on in the Iraq and Afghanistan wars and includes over 100 combat patients with vascular injuries. Details regarding amputation rates, vascular repair in far forward surgical settings and additional operative interventions required up-range are discussed.

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Hemorrhage control in the battlefield: role of new hemostatic agents

Alam HB; Burris D; DaCorta JA; Rhee P.

Military Medicine. 170(1):63-9, 2005 Jan.

Rationale for inclusion: Lethal hemorrhage not amenable to compression or tourniquet can be addressed with hemostatic agents. Brief history of origin of hemostatic agents. Chitosan (Poly-N-acetyl glucosamine); Hemcon. Human fibrin dressing. Mineralized Zeolite (original Quikclot)- exothermic reaction.

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Combat trauma experience with the United States Army 102nd Forward Surgical Team in Afghanistan.

Beekley AC, Watts DM.

Am J Surg. 2004 May;187(5):652-4.

Rationale for inclusion: This retrospective review of the FST is an account of the initial set up and experience in the forward setting and ausetere environment.

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Tourniquets for hemorrhage control on the battlefield: a 4-year accumulated experience.

Lakstein D, Blumenfeld A, Sokolov T, Lin G, Bssorai R, Lynn M, Ben-Abraham R.

J Trauma. 2003 May;54(5 Suppl):S221-5.

Rationale for inclusion: This study utilizes data that mostly pre-dates the US involvement in the Iraq and Afghanistan. The Israeli Defense Forces provide data supporting tourniquet use by pre-hospital medical and non-medical personnel as means of hemorrhage control in those with exsanguinating extremity wounds.

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Tactical combat casualty care in special operations.

Butler FK Jr, Hagmann J, Butler EG.

Mil Med. 1996 Aug;161 Suppl:3-16.

Rationale for inclusion: This paper presents the results of a study that evaluated the appropriateness of the measures used by combat medics. A new basic management protocol was proposd that organized combat casualty care into 3 phases with appropriate measures.

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Acute arterial injuries in Vietnam: 1,000 cases.

Rich NM, Baugh JH, Hughes CW.

J Trauma. 1970 May;10(5):359-69.

Rationale for inclusion: This is a large review with data on mechanism of injury, location of injury, management choices, morbidity and mortality by another giant in military surgery, Dr. Norm Rich.

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Battle injuries of the arteries in World War II: an analysis of 2,471 cases.

Debakey ME, Simeone FA.

Ann Surg. 1946 Apr;123(4):534-79.

Rationale for inclusion: As much a historical lesson than a scientific paper, Dr. DeBakey reviews over 2000 cases of vascular injuries compared from civil war through WWII. There are detailed descriptions of anatomic injuries, amputation rates, options for repair, etc.

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