Traumatic combat injuries differ from those encountered in the civilian setting in terms of epidemiology, mechanism of wounding, pathophysiologic trajectory after injury, and outcome. Except for a few notable exceptions, data sources for combat injuries have historically been inadequate. Although the pathophysiologic process of dying is the same (i.e., dominated by exsanguination and central nervous system injury) in both the civilian and military arenas, combat trauma has unique considerations with regard to acute resuscitation, including (1) the high energy and high lethality of wounding agents; (2) multiple causes of wounding; (3) preponderance of penetrating injury; (4) persistence of threat in tactical settings; (5) austere, resource-constrained environment; and (5) delayed access to definitive care. Recognition of these differences can help bring focus to resuscitation research for combat settings and can serve to foster greater civilian-military collaboration in both basic and transitional research.
For the past 35 years, that is, since the Vietnam War, advances in trauma care have largely occurred in the civilian setting, with improved treatments and systems of care resulting in better outcomes. Whether such improvements are applicable to injuries sustained in combat is the source of ongoing discussion.
The characteristics of combat injuries differ from those of injuries encountered in civilian practice in terms of epidemiology, mechanism of wounding, pathophysiologic trajectory after injury, and outcome. Furthermore, the nature of combat injuries is likely to change because of changes in the ways wars will be fought; such changes may influence therapeutic tactics and techniques, and military medical planning and logistics.
The distribution of the mechanisms of combat injuries is strongly dependent on the branch of military service and how the combat is fought (Table 1). 1-4 For instance, 90% of combat injuries occurring in infantry combat have been caused by penetrating missiles, a proportion very different from that observed in naval and air combat and, indeed, in civilian trauma, in which blunt trauma predominates.
The incidence of thermal injuries is particularly high in certain military environments. For example, on board ship and among the crews of armored fighting vehicles, a figure as high as 47% was quoted for American tank crews during World War II, but this varied from the most minor to the most major burn. Of note, in these settings burns are frequently just one element of multiple-cause injuries to a combatant that might include both blast and penetrating injury.
Today, primary blast injury is relatively uncommon, but there is great concern that the development of modern explosive devices including thermobaric weapons and fuel-air explosives may make blast injury more predominant among combat injuries in the future. At present, the majority of combat injuries are penetrating, and most are caused by fragments from explosive munitions such as shells or grenades (70-80%) rather than bullets fired by military small arms. 5