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Impact of Improved Combat Casualty Care on Combat Wounded Undergoing Exploratory Laparotomy and Massive Transfusion

Simmons, John W. MD; White, Christopher E. MD, FACS; Eastridge, Brian J. MD, FACS; Holcomb, John B. MD, FACS; Perkins, Jeremy G. MD; Mace, James E. MD; Blackbourne, Lorne H. MD, FACS

The Journal of Trauma: Injury, Infection, and Critical Care: July 2011 - Volume 71 - Issue 1 - p S82-S86
doi: 10.1097/TA.0b013e3182218ddb
Original Article

Background: Studies have shown decreased mortality after improvements in combat casualty care, including increased fresh frozen plasma (FFP):red blood cell (RBC) ratios. The objective was to evaluate the evolution and impact of improved combat casualty care at different time periods of combat operations.

Methods: A retrospective review was performed at one combat support hospital in Iraq of patients requiring both massive transfusion (≥10 units RBC in 24 hours) and exploratory laparotomy. Patients were divided into two cohorts based on year wounded: C1 between December 2003 and June 2004, and C2 between September 2007 and May 2008. Admission data, amount of blood products and fluid transfused, and 48 hour mortality were compared. Statistical significance was set at p < 0.05.

Results: There was decreased mortality in C2 (47% vs. 20%). Patients arrived warmer with higher hemoglobin. They were transfused more RBC and FFP in the emergency department (5 units ± 3 units vs. 2 units ± 2 units; 3 units ± 2 units vs. 0 units ± 1 units, respectively) and received less crystalloid in operating room (3.3 L ± 2.2 L vs. 8.5 L ± 4.9 L). The FFP:RBC ratio was also closer to 1:1 in C2 (0.775 ± 0.32 vs. 0.511 ± 0.21).

Conclusions: The combination of improved prehospital care, trauma systems approach, performance improvement projects, and improved transfusion or resuscitation practices have led to a 50% decrease in mortality for this critically injured population. We are now transfusing blood products in a ratio more consistent with 1 FFP to 1 RBC. Simultaneously, crystalloid use has decreased by 61%, all of which is consistent with hemostatic resuscitation principles.

From the United States Army Institute of Surgical Research (C.E.W., B.J.E., L.H.B.), Fort Sam Houston, Texas; Center for Translational Injury Research (J.B.H.), University of Texas, Houston, Texas; Department of Hematology-Oncology (J.G.P.), Walter Reed Army Medical Center, Washington DC; and Department of Surgery (J.E.M.), Brooke Army Medical Center, Fort Sam Houston, Texas.

Submitted for publication March 10, 2011.

Accepted for publication April 26, 2011.

The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the Department of Defense or the US government. This work was prepared as part of their official duties, and as such, there is no copyright to be transferred.

Address for reprints: John W. Simmons, MD, CPT, Institute of Surgical Research, 3400 Rawley E. Chambers Avenue, Fort Sam Houston, TX 78234; email:

© 2011 Lippincott Williams & Wilkins, Inc.