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Prehospital interventions performed in a combat zone: A prospective multicenter study of 1,003 combat wounded

Lairet, Julio R. DO; Bebarta, Vikhyat S. MD; Burns, Christopher J. MD; Lairet, Kimberly F. MD; Rasmussen, Todd E. MD; Renz, Evan M. MD; King, Booker T.; Fernandez, William MD; Gerhardt, Robert MD; Butler, Frank; DuBose, Joseph MD; Cestero, Ramon MD; Salinas, Jose PhD; Torres, Pedro RN; Minnick, Joanne RN; Blackbourne, Lorne H. MD

Journal of Trauma and Acute Care Surgery: August 2012 - Volume 73 - Issue 2 - p S38–S42
doi: 10.1097/TA.0b013e3182606022
Pre-Hospital Clinical Research

BACKGROUND Battlefield care given to a casualty before hospital arrival impacts clinical outcomes. To date, the published data regarding care given in the prehospital setting of a combat zone are limited. The purpose of this study was to describe the incidence and efficacy of specific prehospital lifesaving interventions (LSIs; interventions that could affect the outcome of the casualty), consistent with the Tactical Combat Casualty Care paradigm, performed during the resuscitation of casualties in a combat zone.

METHODS We performed a prospective observational study between November 2009 and November 2011. Casualties were enrolled as they were treated at six US surgical facilities in Afghanistan. Descriptive data were collected on a standardized data collection form and included mechanism of injury, airway management, chest and hemorrhage interventions, vascular access, type of fluid administered, and hypothermia prevention. On arrival to the military hospital, the treating physician determined whether an intervention was performed correctly and whether an intervention was not performed that should have been performed (missed LSI).

RESULTS A total of 1,003 patients met the inclusion criteria. Their mean (SD) age was 25 (8.5) years and 97% were male. The mechanism of injury was explosion in 60% of patients, penetrating in 24% of patients, blunt in 15% of patients, and burn in 0.8% of patients. The most commonly performed LSIs included hemorrhage control (n = 599), hypothermia prevention (n = 429), and vascular access (n = 388). Of the missed LSIs, 252 were identified with the highest percentage of missed opportunities being composed of endotracheal intubation, chest needle decompression, and hypotensive resuscitation. In contrast, tourniquet application had the lowest percentage of missed opportunities.

CONCLUSIONS In our prospective study of prehospital LSIs performed in a combat zone, we observed a higher rate of incorrectly performed and missed LSIs in airway and chest (breathing) interventions than hemorrhage control interventions. The most commonly performed LSIs had lower incorrect and missed LSI rates.

LEVEL OF EVIDENCE Prognostic study, level III.

From the Department of Emergency Medicine (J.R.L., V.S.B.), San Antonio Military Medical Center, San Antonio; Navy Combat Casualty Care (C.J.B., R.C.), Naval Medical Research Unit San Antonio, San Antonio; US Army Institute of Surgical Research (K.F.L., T.R., E.M.R., B.T.K., R.G., L.H.B., J.S.), Houston, Texas; Boston Medical Center (W.F.), Boston, Massachusetts; Tactical Combat Casualty Care Program (F.B.), San Antonio, Texas; R Adams Cowley Shock Trauma Center (J.D.), Air Force/C-STARS, University of Maryland Medical System, Baltimore, Maryland; and Enroute Care Research Center (J.R.L., P.T., J.M.), Houston, Texas.

This article was presented at the 2011 Advanced Technology Applications for Combat Casualty Care (oral presentation) and at the 2012 National Association of EMS Physicians Annual Meeting (poster presentation).

Address for reprints: Julio R. Lairet, DO, Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio, TX; email:

© 2012 Lippincott Williams & Wilkins, Inc.