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Died of Wounds on the Battlefield: Causation and Implications for Improving Combat Casualty Care

Eastridge, Brian J. MD; Hardin, Mark MD; Cantrell, Joyce MD; Oetjen-Gerdes, Lynne MS; Zubko, Tamara; Mallak, Craig MD; Wade, Charles E. PhD; Simmons, John MD; Mace, James MD; Mabry, Robert MD; Bolenbaucher, Rose MD; Blackbourne, Lorne H. MD

The Journal of Trauma: Injury, Infection, and Critical Care: July 2011 - Volume 71 - Issue 1 - p S4-S8
doi: 10.1097/TA.0b013e318221147b
Original Article

Background: Understanding the epidemiology of death after battlefield injury is vital to combat casualty care performance improvement. The current analysis was undertaken to develop a comprehensive perspective of deaths that occurred after casualties reached a medical treatment facility.

Methods: Battle injury died of wounds (DOW) deaths that occurred after casualties reached a medical treatment facility from October 2001 to June 2009 were evaluated by reviewing autopsy and other postmortem records at the Office of the Armed Forces Medical Examiners (OAFME). A panel of military trauma experts classified the injuries as nonsurvivable (NS) or potentially survivable (PS), in consultation with an OAFME forensic pathologist. Data including demographics, mechanism of injury, physiologic and laboratory variables, and cause of death were obtained from the Joint Theater Trauma Registry and the OAFME Mortality Trauma Registry.

Results: DOW casualties (n = 558) accounted for 4.56% of the nonreturn to duty battle injuries over the study period. DOW casualties were classified as NS in 271 (48.6%) cases and PS in 287 (51.4%) cases. Traumatic brain injury was the predominant injury leading to death in 225 of 271 (83%) NS cases, whereas hemorrhage from major trauma was the predominant mechanism of death in 230 of 287 (80%) PS cases. In the hemorrhage mechanism PS cases, the major body region bleeding focus accounting for mortality were torso (48%), extremity (31%), and junctional (neck, axilla, and groin) (21%). Fifty-one percent of DOW casualties presented in extremis with cardiopulmonary resuscitation upon presentation.

Conclusions: Hemorrhage is a major mechanism of death in PS combat injuries, underscoring the necessity for initiatives to mitigate bleeding, particularly in the prehospital environment.

From the United States Army Institute of Surgical Research (B.J.E., M.H., C.E.W., J.S., J.M., R.M., R.B., L.H.B.), Fort Sam Houston, Texas; and Office of the Armed Forces Medical Examiner (J.C., L.O.-G., T.Z., C.M.), Rockville, Maryland.

Submitted for publication March 18, 2011.

Accepted for publication April 22, 2011.

The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Army Medical Command, Department of the Army, or the Department of Defense.

Address for reprints: Brian J. Eastridge, MD, U.S. Army Institute of Surgical Research, 3400 Rawley E. Chambers Ave, Fort Sam Houston, TX 78234-6315; email:

© 2011 Lippincott Williams & Wilkins, Inc.