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Death on the battlefield (2001–2011): Implications for the future of combat casualty care

Eastridge, Brian J. MD; Mabry, Robert L. MD; Seguin, Peter MD; Cantrell, Joyce MD; Tops, Terrill MD; Uribe, Paul MD; Mallett, Olga; Zubko, Tamara; Oetjen-Gerdes, Lynne; Rasmussen, Todd E. MD; Butler, Frank K. MD; Kotwal, Russell S. MD; Holcomb, John B. MD; Wade, Charles PhD; Champion, Howard MD; Lawnick, Mimi; Moores, Leon MD; Blackbourne, Lorne H. MD

Journal of Trauma and Acute Care Surgery: December 2012 - Volume 73 - Issue 6 - p S431–S437
doi: 10.1097/TA.0b013e3182755dcc

BACKGROUND Critical evaluation of all aspects of combat casualty care, including mortality, with a special focus on the incidence and causes of potentially preventable deaths among US combat fatalities, is central to identifying gaps in knowledge, training, equipment, and execution of battlefield trauma care. The impetus to produce this analysis was to develop a comprehensive perspective of battlefield death, concentrating on deaths that occurred in the pre–medical treatment facility (pre-MTF) environment.

METHODS The Armed Forces Medical Examiner Service Mortality Surveillance Division was used to identify Operation Iraqi Freedom and Operation Enduring Freedom combat casualties from October 2001 to June 2011 who died from injury in the deployed environment. The autopsy records, perimortem records, photographs on file, and Mortality Trauma Registry of the Armed Forces Medical Examiner Service were used to compile mechanism of injury, cause of injury, medical intervention performed, Abbreviated Injury Scale (AIS) score, and Injury Severity Score (ISS) on all lethal injuries. All data were used by the expert panel for the conduct of the potential for injury survivability assessment of this study.

RESULTS For the study interval between October 2001 and June 2011, 4,596 battlefield fatalities were reviewed and analyzed. The stratification of mortality demonstrated that 87.3% of all injury mortality occurred in the pre-MTF environment. Of the pre-MTF deaths, 75.7% (n = 3,040) were classified as nonsurvivable, and 24.3% (n = 976) were deemed potentially survivable (PS). The injury/physiologic focus of PS acute mortality was largely associated with hemorrhage (90.9%). The site of lethal hemorrhage was truncal (67.3%), followed by junctional (19.2%) and peripheral-extremity (13.5%) hemorrhage.

CONCLUSION Most battlefield casualties died of their injuries before ever reaching a surgeon. As most pre-MTF deaths are nonsurvivable, mitigation strategies to impact outcomes in this population need to be directed toward injury prevention. To significantly impact the outcome of combat casualties with PS injury, strategies must be developed to mitigate hemorrhage and optimize airway management or reduce the time interval between the battlefield point of injury and surgical intervention.

Understanding battlefield mortality is a vital component of the military trauma system. Emphasis on this analysis should be placed on trauma system optimization, evidence-based improvements in Tactical Combat Casualty Care guidelines, data-driven research, and development to remediate gaps in care and relevant training and equipment enhancements that will increase the survivability of the fighting force.

From the US Army Institute of Surgical Research (B.J.E., R.L.M., T.E.R., L.H.B.), Fort Sam Houston, Texas; Armed Forces Medical Examiner Service (P.S., J.C., T.T., P.U., O.M., T.Z., F.K.B., R.S.K., J.B.H., C.W., H.C., M.L., L.M.), Mortality Surveillance Division, Rockville, Maryland.

Deceased (L.O.-G.).

The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the US Department of the Army or the US Department of Defense.

Address for reprints: Brian J. Eastridge, MD, Professor of Surgery, Trauma Medical Director, Trauma and Emergency Surgery University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive (MC 7740), San Antonio, TX 78229; email:

© 2012 Lippincott Williams & Wilkins, Inc.