Jim Holliman, M.D., F.A.C.E.P. Program Manager

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

2. 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

3. Lecture Acknowledgement • Many thanks to Dr. Joe Lex for many of the slides I stole from him for this lecture

4. 25% 10% 9% 5% 12% 7% 31% 1 % How People Die in Ground Combat KIA : CNS injury KIA : Airway obstruction KIA : Blast / mutilating trauma KIA : Tension PTX KIA : Torso trauma, not correctable KIA : Torso trauma, correctable KIA : Extremity exsanguination DOW : Infection, shock complications (KIA = Killed in Action ; DOW = Died of Wounds)

5. How People Die in Ground Combat KIA: CNS injury KIA: Airway obstruction 25% 10% KIA: Blast / mutilating trauma 9% Can potentially save 15% ! KIA: Tension PTX 5% KIA: Torso trauma, not correctable 12% 7% 31% KIA: Torso trauma, correctable 1% KIA: Extremity exsanguination DOW: Infection, shock complications

6. Location of Death for Fatally Wounded

9. 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

10. 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

11. Battlefield Lessons : First Life-Saving 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

12. 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

13. 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

14. 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

15. 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 %

16. 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

17. 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

18. Blast Victim With Improvised Tourniquets

19. Blast Injury Mechanisms

20. 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

21. 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

22. Blast Lung

23. 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

24. Final Category of Injury to Suspect in the Blast Victim • Auditory System • Tympanic membrane rupture • Ossicular fractures • Cochlear damage

25. 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 :  O2saturation signals early blast lung before symptoms develop

26. 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

27. 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)

28. 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

29. 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 %

30. 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

31. 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

32. Combat Application Tourniquet™

33. Step 1 : Insert the wounded extremity through the loop of the self-adhering band

34. Step 2 : Pull the self-adhering band tight and securely fasten it back on itself.

35. Step 3 : Adhere the band around the arm. Do not adhere the band past the clip.

36. Step 5 : Lock the rod in place with the Windlass Clip™.

37. Step 6 : Adhere the band over the rod.

38. 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

39. 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

41. 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

42. 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

43. Ruins of Darulaman Palace in south Kabul

44. Hopeful sign from a refugee camp in Kabul

45. QUESTIONS ? Thank You for Your Attention